











I<i<5*i«i<I«i«i«5«i3 


















SURGICAL DIAGNOSIS 



BY 



EDWAED MAKTIN, M.D. 

PROFESSOR OF CLIXICAL SXTRGERY IX THE TJXIVERSITY OF PEXXSYLVAXIA 



ITllustrate^ witb 445 BuGtaptngs an^ 18 plates 
in Colors ant) mionocbrome 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1909 



A~^ . 



Entered according to Act of Congress, in the year 1909, by 

LEA & FEBIGER, 

in the Office of the Librarian of Congress. All rights reserved. 



©^■-^■i^ 


iqocj\ 


C. A 24^6914 1 


SEP 22 


1909 



0" 



TO 



J. WILLIAM WHITE, M.D., Ph.D., LL.D. (Bdin.) 

JOHN RHEA BARTON PROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA 



IN RECOGNITION OF HIS SKILL AS A SURGEON AND HIS ABILITY 
AND DEVOTION AS A TEACHER 



THIS BOOK IS DEDICATED 



BY THE 



AUTHOR 



■ -J 

7 ' (r 

I 



PREFACE. 



The simplicity and safety of surgical intervention are, as a rule, 
proportionate to timeliness in diagnosis. This, in turn, is usually 
dependent upon the judgment of the general practitioner, who is, as 
a rule, the first to see the patient and should, therefore, be qualified 
to determine at the earliest moment when surgical treatment is required. 
The practitioner cannot be expected, however, to acquire such a knowl- 
edge of the probabilities deducible from general symptoms and of the 
variations from type as is necessary to establish the final diagnosis. This 
can be gained only by a conscious or subconscious grouping of the clini- 
cal features of many similar cases. 

The proof of the advantage of early diagnosis is afforded by the 
lessened mortality which is found to result from such diagnosis in every 
department of modern operative surgery. This is in part due to more 
perfected technique and more rational after treatment, but mainly to 
the simplicity of earlier operation. To this element is also due, almost 
entirely, the larger percentage of radical cures. 

Partly from custom^ but mainly because of examination requirements, 
it is the habit of teaching institutions to impress upon the minds of their 
students the symptom-complex of the completely developed disease. 
Such clear mental pictures are highly desirable from many points of 
view, but since action is often deferred until the picture is complete, 
they may work to the detriment of the patient. It too often happens 
that when the disease is so fully developed that the diagnosis can be 
made beyond doubt, the time for surgical intervention is past. If, for 
instance, a cancer of the breast is not recognized as possibly or probably 
such until the dense induration, skin adhesion, nodular lymphatic 
glands, and cachexia prove its nature, the only possible result accruing 
to the patient is the knowledge that she will have but little time to live 
and that she will suffer much. There are many affections, the neoplasms 
constituting the most conspicuous examples among these, in which an 
assured diagnosis other than by operative means is impossible at the 
time it is likely to be serviceable. It seems reasonable to hope that 
death or crippling or disfiguring deformity from surface or orificial 
malignant neoplasm may become even more rare than are now those 
monstrous growths which illustrate the text-books and frequent the 
clinics. This end will have been attained in part when it becomes 
generally recognized that the diagnosis of malignancy should be formu- 
lated by wide removal and microscopic examination of any persistent 
outgrowth, infiltration, or ulceration which is not certainly benign. The 



vi PREFACE 

gross deformity of Pott's disease, the crippling ankylosis of coxalgia, 
the life-long pain and disability following bone and joint traumata too 
often represent sequelae which could have been averted but for a too 
faithful adherence to the rule of formulating the diagnosis and directing 
the treatment only upon the basis of a complete symptomatology. 

It is, therefore, in the interest of early diagnosis in its relation to 
helpful and curative surgery that this book is written. Consequently, 
stress is laid mainly upon symptoms of major and deciding moment; 
or, when such are absent, upon the operative and laboratory means by 
which a conjecture may be transformed into a probability or a certainty. 

In the section devoted to Laboratory Diagnosis, Dr. Warfield T. 
Longcope has presented, with a moderation highly creditable, a state- 
ment of the help that may be given the surgeon by those who work 
with the microscope, culture media, and test-tube. 

Dr. Henry K. Pancoast has shown in his chapter on the X-rays in 
Surgical Diagnosis both the value and the limitations of a method which, 
because of its efficiency, is now as essential to the surgeon in his exami- 
nation of patients as is the anesthetic in his operations upon them. 
Dr. Pancoast's outline drawings of negatives in his possession constitute 
the most complete series of x-raj fracture pictures yet published. 

In the chapter devoted to Gynecological Diagnosis, Dr. Brooke M. 
Anspach has admirably described in detail the methods found most 
serviceable in his hospital and private practice. 

Dr. Theodore H. Weisenburg has based his chapter on the Diagnosis 
of Nervous Affections upon a wide experience with those diseases of the 
nervous system in which surgical intervention must be considered. 

Such merit and accuracy of statement as may be found in the section 
devoted to the Eye are due to the criticisms and suggestions of Dr. 
George E. de Schweinitz. 

E. M. 
Philadelphia, 1909. 



CONTENTS 



CHAPTER I. 
Laboratory Diagnosis 17 

CHAPTER II. 

The Application of the X-rays in Surgical Diagnosis 37 

CHAPTER III. 
Inflammation 68 

CHAPTER IV. 

Complications and Sequels of Trauma 78 

CHAPTER V. 
Tumors 82 

CHAPTER VI. 
The Skin 84 

CHAPTER VII. 
The Bloodvessels 96 

CHAPTER VIII. 

The Lymph Vessels and Glands 101 

CHAPTER IX. 

The Muscles, Tendons, and Burs^ 107 

CHAPTER X. 
The Bones and Joints 118 

CHAPTER XL 
Diseases of the Nervous System 140 



viii CONTENTS 

CHAPTER XII. 
The Head, Face, and Neck 223 

CHAPTER XIII. 
The Spinal Column 332 



CHAPTER XIV. 
The Upper Extremity 345 



CHAPTER XV. 
The Thorax 451 

CHAPTER XVI. 
The Abdomen 477 

CHAPTER XVII. 
The Lower Extremity 556 

CHAPTER XVIII. 
The Genito-urinary Organs 640 

CHAPTER XIX- 
Gynecological Diagnosis . . .' 693 



Index 739 



SURGICAL DIAGNOSIS 



CHAPTER I. 

LABORATORY DIAGNOSIS. 

By WARFIELD T. LONGCOPE, M.D. 

EXAMINATION OF THE BLOOD. 

At the present time our knowledge of the chemistry of the blood and 
blood serum is not sufficiently advanced to offer much aid in the practical 
study of a patient. In certain conditions a spectroscopic examination 
of the blood may reveal the presence of an abnormal substance, such as 
carbon monoxide hemoglobin. Until more knowledge has been accu- 
mulated, too, regarding the variations in the reactions of the blood, 
estimations of the alkalinity cannot prove of much value. 

On the other hand, a determination of the coagulation time of the blood 
may be of great importance. To a surgeon who is about to operate, a 
knowledge of the fact that the formation of a blood clot is delayed twenty 
or thirty minutes may obviate an unpleasant experience. To estimate 
the coagulation time of the blood, Wright's tubes may be used, but the 
new instrument devised by Boggs is much simpler in application and 
probably more accurate. The most common condition in which the 
time of coagulation shows the greatest diminution is jaundice, especially 
when incident to chronic pancreatitis; in severe cases the blood may 
remain fluid after withdrawal for fifteen to twenty-five minutes. It must 
be remembered that in hemophilia, a disease which offers great dangers 
to the surgeon, the coagulation time of the blood may not be decreased. 

The estimation of the hemoglobin, a procedure which may be done 
with the greatest ease, will decide quickly whether or not the patient has 
an anemia, and combined with an enumeration of the red blood corpuscles 
may give much information. In many of the acute infections, in chronic 
suppurative conditions, in cachexias due to malignant growths, in cirrhosis 
of the liver, and in Bright's disease, there is always more or less secondary 
anemia, with a greater loss proportionately in the amount of hemoglobin 
than in the numbers of red blood cells. Immediately after an acute 
hemorrhage the blood picture may be very nearly normal, for the 
absorption of fluid from the blood is so great that the loss of the 
formed elements is not obvious. Later, a loss in hemoglobin, relative 
to the size of the hemorrhage, and a less marked reduction in the red cells 
2 



18 LABORATORY DIAGNOSIS 

become evident. When small but frequent hemorrhages take place the 
diminution of hemoglobin and loss of red blood corpuscles progress 
slowly, but finally the blood picture may reach that of an extreme grade 
of anemia. The anemia in the above condition is due either to an 
actual loss of red blood cells through hemorrhage or to a destruction 
of red blood cells in the circulation through the action of some toxic or 
poisonous substances. Smears from the blood show that the red blood 
cells are small and pale (Plate I). There may be some irregularity in 
size and shape of the cells, but this is not usually marked. Except 
in the severest secondary anemias, nucleated red blood cells are not 
numerous, and almost always when present they are of the normo- 
blastic type. 

Progressive pernicious anemia is to be sharply differentiated from the 
great group of secondary anemias. The exact cause of pernicious 
anemia is not known, but its mode of origin is different from that of the 
secondary anemias, inasmuch as the anemia is not alone due to a 
destruction of red cells in the circulating blood, but to an injury of the 
vital tissue which forms the red blood cells for the body — the bone mar- 
row. The red corpuscles in this disease fall relatively lower than the 
hemoglobin, so that the hemoglobin index is above 1. The leukocytes are 
decreased. Microscopically the red blood corpuscles show great irregu- 
larity in size and shape (Plate II). Many of them are much larger 
than normal. Nucleated red blood corpuscles are found, sometimes 
in great numbers, and the megaloblasts are often more plentiful than 
the normoblasts. The blood picture serves to distinguish cases of 
pernicious anemia from severe secondary anemia, which may accompany 
hidden carcinoma of the internal organs, or follow repeated losses of 
small amounts of blood. 

Great importance has been attached, within recent years, to estima- 
tions of the white cells or leukocytes of the blood. In dealing with this 
subject it must be remembered that the leukocytes play a very definite 
part in the economy of the body, and, so far as we know at present, are 
principally concerned in protecting the organism against injurious agents, 
among which are certain pathogenic bacteria. 

The knowledge that the numbers of these cells in the circulating blood 
may vary greatly from normal, in many acute diseases, and even in some 
chronic affections, has been of much assistance in the diagnosis of certain 
conditions. Under normal circumstances the variation in the numbers 
of the leukocytes is not very great, and we can consider 7000 to 10,000 
leukocytes per c.mm. within the normal limits. When the leukocytes 
are increased, perhaps to 15,000, to 20,000, or to 50,000 per c.mm., we 
speak of the condition as leukocytosis; and when they fall below the 
normal limit, the condition is known as leukopenia. 

Several varieties of leukocytes go to make up the total number of these 
white cells, and of all the leukocytes, the polymorphonuclear neutrophilic 
leukocytes are the most numerous. They form 70 per cent, to 72 per cent, 
of the cells. Next in numbers are the small lymphocytes, which make 
up 22 per cent, to 25 per cent, of the cells. The large lymphocytes and 



/}y/ 




0»AlVfi BY J.N1 CnASi 



PLATE I 

BLOOD. 

(Elu-licli triple stain.) 
(Prepared by Dr. I. P. Lvox.) 

Fig. I. TYPES OF LEUCOCYTES. 

a. Polymopphonueleap Neutpophile. b. Polymorphonuclear Eosinophile. c. Myelocyte 
(Neutrophilic), d. Eosinophilic Myelocyte, e. Large Lymphocyte (large Mononuclear). 
/. Small Lymphocyte (small Mononuclear). 

Fig. IL NORMAL BLOOD. 
Field contains one neutrophile. Reds are normal. 

Fig. IIL ANEMIA, POST-OPERATIVE (secondary). 

The reds are fewer than normal, and are deficient in haemoglobin and somewhat 
irregular in form. One normoblast is seen in the field, and two neutrophiles and one 
small lymphocyte, showing a marked post-haemorrhagic anaemia, with leucocytosis. 

Fig. IV. LEUCOCYTOSIS, INFLAMMATORY. 

The reds are normal. A marked leucocytosis is shown, with five neutrophiles and 
one small lymphocyte. This illustration may also serve the purpose of showing tha 
leucocytosis of malignant tumor 

Fig. V. TRICHINOSIS. 
A marked leucocytosis is shown, consisting of an eosinophilia. 

Fig. VI. LYMPHATIC LEUKEMIA. 

Slight anaemia. A large relative and absolute increase of the lymphocytes Cchiefly 
the small lymphocytes) is shown. 

Fig. VII. SPLENO-MYELOGENOUS LEUKEMIA. 

The reds show a secondary anaemia. Two normoblasts are shown. The leucocytosis 
is massive. Twenty leucocytes are shown, consisting of nine neutrophiles, seven myelo- 
cytes, two small lymphocytes, one eosinophile (polymorphonuclear) and one eosinophilic 
myelocyte. Note the polymorphous condition of the leucocytes, i.e., their variations 
from the typical in size and form. 

Fig. VIII. VARIETIES OF RED CORPUSCLES. 

a. Normal Red Corpuscle (normocyte), b, c. Anaemic Red Corpuscles, d-g'. Poikilocytes. 
h. Microcyte. i. Megalocyte. j-n. Nucleated Red Corpuscles., j;, fc. Normoblasts. I. Micro- 
blast. m,n. Megaloblasts. 




Pernicious Anaemia. 

The field shows marked anisocytosis and poikilocytosis: .V, young megaloblast (early generation); 
yP -I/'* .1/'', later generations of the megaloblast series; <S S S, " stippled" red ceils; R, ring body (nuclear 
remnant ?); T., lymphnr-yte. 

FIG. 2 




Pernicious Anaemia. (Actual Field.) 

Field showing less poikilocytosis than Fig. 1: .l/i, young megaloblast; ,1/2, megaloblast of later 
generation; T T T, etc., transitional erythroblasts, not typical either of the megaloblastic or of the 
normoblastic series; .S, " stippled" erythrocyte; P. polynuclear neutrophile; L. large lymphocyte. 



BXAMINATION OF THE BLOOD 19 

transitional cells form 3 per cent, to 5 per cent., the eosinophilic leukocytes 
2 per cent, to 4 per cent., and the basophiles 0.5 per cent. 

In the commoner forms of leukocytosis these cells do not increase 
proportionately. One form predominates above all others, both relatively 
and in actual numbers, and this form is the polymorphonuclear leukocyte. 
The reason for this is not far to seek. If one injects a culture of some 
bacterium, such as Staphylococcus aureus, into the peritoneal cavity of 
a rabbit, the polymorphonuclear leukocytes pour from the bloodvessels 
of the mesentery into the peritoneal cavity to protect the body against the 
toxic action of the bacteria. So many leukocytes leave the blood stream 
that for a short time the numbers of white cells in the peripheral circula- 
tion are actually diminished. But the body soon feels the need of more 
leukocytes. Great quantities of these cells are required in the perito- 
neum, and they must reach the peritoneum from their point of origin 
through the blood stream. New leukocytes, therefore, are rapidly 
formed in the bone marrow and poured in great numbers into the cir- 
culation, whence they find their way to the peritoneum. This generous 
supply of cells circulating through the bloodvessels produces the leuko- 
cytosis. 

If, now, a culture is chosen which is extremely virulent, and if this is 
inoculated into the animal in great quantity, the rabbit may die very soon 
and without the appearance of a leukocytosis. The explanation of this 
fact is found in the severity of the intoxication. The body cells, including 
those which form the leukocytes, are so badly injured by the bacterial 
toxins that leukocytes cannot be formed readily; not only is it impossible 
for the body to furnish leukocytes in excess of what is required, but it 
cannot even produce sufficient numbers to combat the infection. 

It may readily be seen that leukocytoses cannot be considered by rule 
of thumb. When great quantities of leukocytes are required for some 
purpose in any part of the body, the body cells do their best to produce 
leukocytes in excess of what is actually needed, and the number of these 
cells increase in the blood. 

Though it is impossible to draw definite conclusions from the grade 
of leukocytosis, still certain general principles may be followed in those 
infections where a leukocytosis usually occurs. If the patient is not 
very sick and the leukocytes are only slightly increased, we may assume 
that the infection is mild and great numbers of leukocytes are not 
required for protection. If the patient is very ill and the leukocytes 
are high, the body is probably reacting well against the infection, but 
if the patient is very ill and the leukocytes remain low, the reaction of 
the body is poor and the ultimate outlook is grave. 

A leukocytosis may be physiological or pathological. Physiological 
leukocytoses occur after heavy meals, when the white cells may increase 
30 per cent, to 40 per cent., and after excessive exercise and cold baths. 
During pregnancy the leukocytes increase 50 per cent, to 80 per cent., 
while in the newborn the leukocytes may be three to four times their 
normal number in the adult. 

Pathological leukocytoses occur in a great variety of conditions, and 



20 LABORATORY DIAGNOSIS 

certain diseases are almost always accompanied by a leukocytosis. 
Among these conditions may be mentioned pneumonia, rheumatic fever, 
epidemic meningitis, septicemia, erysipelas, scarlet fever, and tetanus. In 
practically all forms of pyogenic infections and purulent inflammations 
there is a leukocytosis of varying degree, and sometimes a leukocytosis 
which is quite high. In localized acute inflammations a leukocytosis is 
the rule, and it is sometimes surprising to find what a marked leukocy- 
tosis accompanies a comparatively mild infection. A small boil may 
give rise to a leukocytosis of 20,000 to 25,000 cells per c.mm. Purulent 
inflammations of the pleura, the pericardium, and the peritoneum are 
usually accompanied by a great increase in the leukocytes. In empyema 
it is not uncommon to find a leukocytosis of 20,000 to 50,000 cells per 
c.mm. The same is true of acute purulent inflammations of the gall- 
bladder and such internal organs as the liver, kidneys, and brain. 

In appendicitis the leukocytes may vary considerably, depending upon 
the stage of the disease. With acute catarrhal conditions the leukocytes, 
if increased at all, are very slightly elevated; in the acute suppurative 
stages there may be a moderate leukocytosis (15,000 to 20,000 leuko- 
cytes per c.mm.), or as the process continues a very high grade of leuko- 
cytosis (30,000 to 40,000 leukocytes per c.mm.) may develop. As is 
true in all infections, the desperate fulminating cases may show but a 
slight rise in the leukocytes. When the process becomes chronic the 
leukocytes may be normal, and even though there is a localized abscess, 
provided it is walled off, the leukocytes may be scarcely above the normal 
limits. This, too, is true of all chronic localized inflammations. During 
the active stage of the infection, new leukocytes are constantly required 
at the seat of trouble and are constantly kept high in the circulating blood; 
but in an old walled-off abscess no leukocytes are required of the body, 
and there is, therefore, no increase of the cells in the blood. 

Though the presence of a leukocytosis may aid in the diagnosis of 
certain conditions, the discovery of a leukopenia may be equally helpful 
in clearing the diagnosis. Just as certain diseases are characterized by 
an increase in the leukocytes others may be recognized by a decrease. 
This is particularly true of typhoid fever, and the knowledge of this fact 
may serve to differentiate this disease from certain acute infections 
which it may so closely resemble. Another very important fact which 
must be borne in mind when one is dealing with typhoid fever is that 
secondary acute inflammations, such as pneumonia, subcutaneous ab- 
scesses, osteomyelitis, cholecystitis, and peritonitis, complicating typhoid, 
may give rise to only a slight leukocytosis, which is in no way comparable 
to the leukocytosis occurring in such acute infections alone. Whereas, 
the leukocytes in croupous pneumonia usually average 15,000 to 30,000 
cells per c.mm., and may be much higher, in pneumonia complicating 
typhoid fever the leukocytes may number only 8000 to 12,000. If one 
takes into account the usual leukopenia of typhoid fever (3000 to 6000 
leukocytes per c.mm.), this represents an increase in the leukocytes of the 
blood, but is insignificant as compared with the leukocytosis seen in 
croupous pneumonia itself. 



EXAMINATION OF THE BLOOD .21 

When a perforation of the bowel takes place in typhoid fever there may 
be a transient increase in the leukocytes, and in rare cases the leukocytosis 
is high. More commonly the white cells increase to 10,000 or 12,000, 
and then, particularly in unfavorable cases, their numbers fall rapidly. 
Often in quickly fatal cases it is impossible to detect any definite rise in 
the leukocytes, and the leukopenia becomes steadily more pronounced 
until death. 

In tuberculosis a leukocytosis makes its appearance only when a 
secondary infection is engrafted upon the original process. 

A few non-inflammatory conditions may give rise to a leukocytosis, 
and unless one is cognizant of this fact, confusion may arise. Acute 
hemorrhage is followed by a leukocytosis which is often very pronounced, 
and the leukocytes may reach as much as 20,000 per c.mm. Less 
marked leukocytoses are seen after intoxications by certain drugs, such 
as phenacetin and antipyrine, and after chloroform narcosis. Occasionally 
a leukocytosis develops during the course of such malignant tumors as 
carcinoma and sarcoma. 

So far we have considered only the leukocytoses which are character- 
ized by an increase in the polymorphonuclear neutrophilic cells, but it is 
also possible to have a leukocytosis due to an increase in the eosinophile 
leukocytes. Eosinophilia occurs in a number of conditions. It is most 
marked in trichinosis and in infections by certain intestinal parasites, 
particularly the ankylostoma duodenale. Eosinophilia may also appear 
during certain stages of bronchial asthma, and may be present in pemphi- 
gus and some varieties of skin diseases. 

The study of the white cells of the blood in the diseases which we have 
mentioned so far, though it may suggest or aid a diagnosis, is not essential 
for the diagnosis. In a few diseases the diagnosis cannot be made 
without a blood examination. 

The diagnosis in leukemia must rest entirely upon a study of the blood. 
There are two main forms of leukemia, lymphatic leukemia and myelo- 
genous leukemia. 

Lymphatic leukemia may again be divided into two types, the acute 
and the chronic. In acute lymphatic leukemia the clinical picture is 
usually that of an acute infection with fever and general prostration. 
The lymph glands are not enlarged, as a rule. The leukocytes are in- 
creased. They may number 50,000 to 200,000 or more. The stained 
smear shows an enormous preponderance of a form of large lymphocytes. 
The chronic variety is characterized by an enlargement of the lymph 
glands and spleen and by a leukocytosis in which the white cells may 
reach from 100,000 to 500,000 per c.mm. In smears the cell which forms 
from 80 per cent, to 95 per cent, of all the white corpuscles is the small 
lymphocyte. In both types the red blood corpuscle and hemoglobin 
may be decreased, but anemia is usually most marked in the acute leuke- 
mias. 

Myelogenous leukemia is characterized by enlargement of the spleen, 
and sometimes of the lymph glands, with, again, a great increase in the 
numbers of white blood corpuscles. Anemia is also present, and the 



22 LABORATORY DIAGNOSIS 

proportion of white and red cells may be 1 to 5 or 1 to 3, or even 1 to 1. 
The stained smear shows a variety of cells which are not normally found 
in the blood. Neutrophilic and eosinophilic myelocytes, cells which 
normally are seen only in the bone marrow, form a large percentage of the 
cells. Nucleated red blood corpuscles may also be seen in large numbers. 
A blood examination is imperative in every patient who has marked 
enlargement of the spleen and general marked enlargement of the 
lymph glands. 

Besides the examination of the formed elements of the blood, one may 
obtain much information through other methods. It is known that when a 
culture of a given bacterium, for instance the typhoid bacillus, is injected 
in non-fatal doses into an animal, the serum of that animal gradually 
develops the property, when brought into contact with a suspension 

Fig. 1 



U^ ■ 


- .1 


-^ffll. 




• ^^^pj 




'^m ** 


■ \:y^ 


■ 





Positive agglutination reaction. 

of cultures of that specific organism, of causing the bacteria to clump 
together in great masses. This is known as agglutination, and the serum 
may develop such high agglutinative properties that it will be active 
when diluted 100, 1000, or even 10,000 times. During the course of 
typhoid fever the serum develops the power of agglutinating the typhoid 
bacillus, and this specific agglutinative reaction (the Widal reaction) is 
made use of for the diagnosis of this disease. In order to say certainly 
that the Widal reaction is positive, the blood serum of a patient, diluted 
at least fifty times and better one hundred times, must stop the motion of 
the typhoid bacilli and cause them to form well defined clumps within 
one hour (Fig. 1). The reaction is rarely present before the second week 
of the disease, and may be delayed until the end of the third or fourth 
week. Serum from patients suffering from certain other bacterial infec- 



EXAMINATION OF THE URINE 23 

tions, such as Malta fever or tuberculosis, may develop the power to 
agglutinate the infecting organisms, though the reaction which is of most 
practical importance is that occurring in typhoid fever. 

Another very valuable serum reaction for diagnosis is the complement 
deviation method of Wasserman. By a technique which is complicated 
and much more elaborate than that of the Widal reaction, it is possible 
to obtain this deviation of the complement of the blood serum in a large 
percentage of syphilitics. The reaction usually fails when the patient 
has been treated for some time by antisyphilitic measures. The 
reaction depends upon the union of a specific antibody present in the 
serum of the syphilitics with a so-called antigen which is present in 
tissue richly infected with Spirocheta pallida. Recently, lecithin has 
been substituted for the syphilitic tissue. During the union of the 
antibody and antigen the thermolabile complement of serum is 
absorbed. The same method of diagnosis has been applied to the 
serum of typhoid and tuberculous patients, an extract of the typhoid 
bacillus and tuberculin being used as antigen. 

More accurate information may be received in systemic bacterial 
infections from blood cultures. Small amounts of blood may be readily 
withdrawn by means of a syringe from the veins at the elbow, and cul- 
tures may be made from this blood on different media. This method 
is of great value for diagnosis in the early stages of typhoid fever, when 
typhoid bacilli may be obtained in 80 to 95 per cent, of the cases. Septi- 
cemia due to the pyogenic cocci or other bacteria may often be discovered 
by this means; or when the diagnosis is suspected it may be confirmed 
and the nature of the infecting organism accurately determined. 

Finally, it is necessary to mention the aid which may be given by an 
examination of the blood for parasites. The discovery of the malarial 
Plasmodia may explain the presence of alarming chills, while it is not 
necessary to emphasize the importance of a search for the embryos of 
Filiaria sanguinis hominis in cases of lymph scrotum and chyluria, for 
Spirillum obermeieri when relapsing fever is suspected, and in rare 
instances for trypanosomes. 



EXAMINATION OF THE URINE. 

Under normal conditions an adult passes from 1500 to 2000 c.c. of 
urine in twenty-four hours. This quantity varies slightly in health, 
according to the amount of fluid taken into the body or the amount of 
fluid lost through sweating, etc. Under pathological conditions the 
amount of urine may vary enormously. It is increased in diabetes 
mellitus and diabetes insipidus, in certain forms of chronic nephritis, 
and in certain nervous disorders, while the amount is decreased princi- 
pally in acute nephritis and certain forms of chronic nephritis. 

In recurring occlusion of the ureters through any cause, or in certain 
forms of hydronephrosis, the quantity of urine may vary from time to 
time. The periods in which the ureters are partially blocked are char- 



24 LABORATORY DIAGNOSIS 

acterized by decreased urinary secretion, while relief of the block is 
followed by marked and often sudden polyuria. 

The specific gravity of the mixed twenty-four-hour urine from healthy 
persons usually lies between 1015 and 1020. After the drinking of much 
water or beer the specific gravity may fall to 1002, or after excessive 
sweating rise to 1035. As a general rule, in diseased states the specific 
gravity of the urine varies with the quantity of urine excreted. A con- 
centrated urine has a high specific gravity, while in polyuria the specific 
gravity is low. There is one glaring exception. In the marked polyuria 
of diabetes mellitus the specific gravity is greatly increased, and may be 
1040 to 1050. 

The urine from a normal person is quite transparent and varies in color 
from a pale yellow to a dark amber. On standing, a flocculent cloud 
forms, which is composed of mucus enclosing a few cells. A precipitate 
of urates or phosphates or a growth of bacteria may cloud the urine 
diffusely. Certain characteristic changes in the color are seen in disease. 
In febrile states the urine becomes dark yellow or reddish; blood, of 
course, imparts a red, smoky appearance, while bile produces a yellow 
or greenish tinge, particularly noticeable in the foam. Besides these 
commoner causes, certain drugs give rise to colored urine. Injection 
of carbolic acid, hydrochinone, and salol produce a dark brown or 
olive-green urine; rhubarb and senna give a yellow color, due to 
chrysophanic acid ; santonin gives either yellow or green ; while methylene 
blue produces a deep blue or green coloration. 

The reaction of freshly voided normal urine is slightly acid, due to the 
presence of several acid salts, the most important of which is diacid 
sodium phosphate. The acidity varies in health according to the type 
of diet, becomes more marked when there is increased consumption of 
proteid, less marked on a vegetable diet, and during different periods 
of the day. Immediately after meals the acidity is lowest. The acidity 
is diminished or the urine becomes alkaline under a variety of circum- 
stances, but most noticeably in the condition known as phosphaturia, 
or when it is mixed with blood or alkaline secretions, or when alkaline 
fermentation takes place anywhere in the urinary tract. The alkaline 
reaction, if it is due to ammonia, is caused by a growth of certain forms 
of bacteria. On standing, urine from normal individuals tends to 
become alkaline through bacterial fermentation. 

Increase in the acidity is rare, though it may occur probably as the 
result of a neurosis, and cause symptoms of cystitis. Cryoscopy, or the 
determination of the freezing point of the urine, may give information 
concerning the activity of the kidneys. A freezing point above 0.9° 
indicates low molecular concentration, and shows that the functional 
activity of the kidneys is interfered with. The value of this method for 
determining the relative activities of the two kidneys from an examination 
of the urine obtained by ureteral catheterization is not unquestionable. 

The presence of albumin in the urine is spoken of as albuminuria, and 
the commonest and most important form of albumin found is serum 
albumin. The finding of albumin in the urine may denote that the 



EXAMINATION OF THE URINE 25 

kidneys have failed, at least partially, in their function as filters, thus 
allowing the passage of albumin from the blood (renal albumin), or it 
may point to the presence of blood or piis in the bladder or kidneys or 
an admixture of seminal or prostatic fluids with the urine (accidental 
albuminuria). 

If the albumin is renal in origin, it is safe at least to suspect disease 
of the kidneys. There is, however, a group of very interesting cases in 
which albuminuria may occur in persons enjoying apparently perfect 
health. This physiological albuminuria may occur under a great 
variety of circumstances. Albuminuria may be present in the urine of 
healthy pregnant women, in men after severe exertion, as in bicycle 
riders or football players, after mental exertion, cold baths, and certain 
other conditions. It is still dubious as to whether the cyclical and 
orthostatic albuminurias are truly functional, and appear in persons 
who have healthy kidneys. 

Albuminuria occurs in most febrile diseases, when there is a degenera- 
tion of the epithelium of the renal tubules, in acute and chronic conges- 
tion of the kidneys, as in heart disease, and in all forms of acute and 
chronic nephritis. In certain forms of acute nephritis the albumin 
may be present in large quantities and measure as much as 1 to 2 per cent, 
when estimated in the Esbach tubes, whereas in certain forms of chronic 
nephritis there may be only 0.1 per cent, to 0.5 per cent., or the albumin 
may only be present in traces. In amyloid diseases 2 to 3 per cent, 
of albumin may be present in the urine. 

In suppurative conditions of the kidneys the albumin comes both 
from the red blood cells and leukocytes of the pus, and from the kidneys 
themselves. Albumin is present in considerable quantity, and usually 
amounts to more than 0.1 per cent. In inflammatory conditions of the 
bladder, however, though albumin is practically present in every severe 
case, it rarely exceeds more than 0.1 per cent, to 0.15 per cent, in amount 
unless blood is present. If, therefore, in acute inflammatory conditions 
of the urinary tract the amount of albumin in the urine, which does not 
contain blood, exceeds 0.2 per cent., one may suspect immediately that 
one or both kidneys is involved. 

Though peptones and albumosis may appear in the urine when there 
is long-continued suppuration in one part of the body, the presence of 
these bodies is not of any great diagnostic significance. 

On the other hand, the presence of Bence Jones' body, which is now 
known to be related more closely to the albumins than albumoses, points 
at once to a disease of the bone marrow, and suggests above all other 
things, those curious tumors called multiple myelomata. The body has 
been found once, in another disease, namely, lymphatic leukemia. 

Nucleo-albumin, a body allied to mucin, has no practical significance. 
Unless the test for albumin is carefully made, nucleo-albumin may be 
mistaken for true serum albumin. 

Fibrin is found in the urine very rarely, and is usually associated with 
chyluria, a condition arising during the course of certain cases of filariasis, 
and in diphtheritic inflammation of the urinary tract. 



26 LABORATORY DIAGNOSIS 

Abnormal excretions of glucose may occur in two great classes of cases : 

(1) Persons suffering from a definite disease, diabetes mellitus, and 

(2) persons who have transient glycosuria. 

The constant presence of sugar in the urine means diabetes mellitus. 
In quantity the sugar may vary from traces to 10 per cent. During 
twenty-four hours a patient may excrete 200 to 300 grams of glucose. 
In mild cases the glucose disappears or decreases markedly when car- 
bohydrates are excluded from the patient's diet. If this does not occur 
the prognosis is bad. 

Transient glycosuria may be of no moment. It may occur after 
ingestion of sugar in abnormal amounts, in certain diseases or injuries 
to the nervous system and digestive tract, after insults or injuries to the 
liver, after fracture of the long bones, after ether anesthesia, in exoph- 
thalmic goitre, and after the use of certain drugs. Injuries to the pancreas 
may give rise to glycosuria, while in certain diseases of the pancreas, 
such as severe chronic interstitial pancreatitis, glycosuria may at first be 
transient and later become constant. 

Acetone is found in the urine in many conditions, but has most sig- 
nificance in diabetes mellitus, when its presence may indicate ap- 
proaching coma. It appears also in fevers, during starvation, after a 
purely proteid diet, in the cachexias due to malignant tumors, after 
chloroform narcosis, in auto-intoxications, certain digestive disturbances, 
and cyclic vomiting. 

Diacetic acid occurs under much the same conditions as acetone, and 
has the same significance in diabetes mellitus. 

^-oxybutyric acid occurs in diabetic coma, and its presence in the urine 
in any quantity in diabetes mellitus signifies almost certainly approaching 
coma. 

When blood appears in the urine, one speaks of hematuria; when the 
coloring matter without the cells is present, the condition is known as 
hemoglobinuria. In hematuria the blood may come from the kidneys, 
the ureter, the bladder, or the urethra. 

Renal hematuria may be caused by injury to the kidneys. It may 
appear when there is a stone in the kidney, in acute inflammation of the 
kidneys, during the course of acute or chronic nephritis, when the kidneys 
are the seat of tumor growth, especially hypernephroma, in purpura 
hemorrhagica, in chronic passive congestion of the kidneys, after carbolic 
acid poisoning, occasionally in acute infectious diseases, such as typhoid 
and smallpox, occasionally in leukemia, or finally, in parasitic disease of 
the kidneys. There is, besides, a primary renal hematuria, the cause of 
which is not definitely determined. Acute inflammation of the ureter 
(often caused by the passage of a stone), bladder, prostate, and urethra 
may cause hematuria. Tumors of the bladder frequently give rise to 
severe hematuria. 

Hemoglobinuria is seen after the ingestion of certain poisonous sub- 
stances, such as potassium chlorate and pyrogallic acid, after the trans- 
fusion of foreign blood, or even after the transfusion of large quantities 
of blood of the same species, in extensive burns, in black-water fever, 
and in the curious condition termed paroxysmal hemoglobinuria. 



EXAMINATION OF THE URINE 27 

Melanin in the urine may point to the presence of a melanotic tumor 
of the kidney. 

The bile pigment, bilirubin, is found in the urine when there is obstruc- 
tion to the bile passages, and is, of course, always present in jaundice. 
Indican and indigo are found in excess in the urine during excessive 
putrefaction of proteid material in the intestinal tract. Indican in the 
urine occurs during interstitial disturbances and particularly in obstruc- 
tion. When the obstruction is in the small bowel, the amount of indican 
is much greater and appears much sooner than when the obstruction 
is in the large intestine. Leucin and tyrosin are the decomposition 
products of albumin and are found in the urine, and in such destructive 
lesions of the liver as acute yellow atrophy. 

The color reaction described by Ehrlich as the diazo reaction may be 
obtained in at least 95 per cent, of all cases of typhoid fever. Unfor- 
tunately the reaction is not specific, for it may occasionally be noted 
in the urines from cases of tuberculosis, pneumonia, septicemia, and 
carcinoma. 

The test devised by Cammidge is said to be specific for diseases of the 
pancreas, and is thought to be especially valuable for the diagnosis of 
chronic inflammation of the pancreas. 

Bacteriology. — The urine in the normal bladder is sterile, but since it 
forms a good culture medium, soon after it is passed bacteria rapidly 
develop in it. During the course of certain bacterial diseases, in which 
there is a septicemia, the infecting bacteria may be eliminated in the urine. 
When the bacteriuria is renal in origin, the organisms most commonly 
found are typhoid and colon bacilli. The typhoid bacilli can be grown 
from the urine in 20 to 30 per cent, of cases of typhoid fever. The 
bacilluria may continue for some time after convalescence, and it may 
be present without setting up a cystitis. Bacteriuria may also be per- 
sistent in cases of localized infection of the prostate and posterior 
urethra. 

Cultures from the urine from cases of inflammation of the urinary 
tract may help to elucidate the condition. The bacteria which are most 
commonly associated with cystitis and inflammation of the ureters and 
kidneys are Bacillus coli. Bacillus proteus, staphylococci, streptococci, 
pneumococci, gonococci, and the tubercle bacillus. If the urine contains 
pus which is sterile and in which no bacteria can be seen with ordinary 
stains, tuberculosis may be suspected. Great care should be observed 
in differentiating the tubercle bacillus from the smegma bacillus. To 
make a positive diagnosis, the urine should be inoculated into guinea- 
pigs. 

Parasites of Urine. — In echinococcus diseases of the kidneys or bladder 
the urine may contain echinococcus booklets or scolices. Chyluria may 
be associated with filariasis, so that if chyluria is observed in any case, the 
urine, but more especially the blood, should be searched carefully for 
filaria embryos. The diagnosis may be made solely by this means. 

The urine in Egyptian hematuria often contains the eggs of the para- 
site Distomum^hematobium, which produces the disease. 



28 LABORATORY DIAGNOSIS 



EXAMINATION OF THE FECES. 



The frequency and the amount of defecation in health vary so greatly 
with the individual and depends upon so many factors that departures 
from normal are often not noted until they have become pronounced. 

The consistency of the fecal mass depends upon the amount of water 
which it contains. An increase of fluid may be caused either by an 
increased exudation or transudation from the intestinal mucous mem- 
brane, or by decreased absorption of water by the intestinal walls. An 
exudation of fluid takes place in inflammation of the mucous membrane, 
while decreased absorption may occur when peristalsis is for any reason 
increased. 

Some information may be gained from the color of the stools. Varia- 
tions in color may depend upon (1) digestive secretions; (2) food residue; 
(3) discharges from the intestinal mucous membrane; (4) accidental 
ingredients, such as drugs. 

The secretion which is of most importance in giving a color to the 
intestinal contents is bile, and the coloring matter is a derivative of 
bilirubin, namely, hydrobilirubin or urobilin. After the first few months 
of life, biliverdin and bilirubin are not present in the normal stool. 

If the stools are free from bile pigmentation, a condition which occurs 
in complete occlusion of the bile ducts, they exhibit a pale color, the 
typical clay-colored stools. 

In many diarrheas the stools may contain bilirubin, owing to the fact 
that the stool is so rapidly carried through the intestinal canal that there 
has not been time to convert these substances into hydrobilirubin. 
These pigments give to the stool a yellow color and in infants the fre- 
quent admixture of biliverdin with the bilirubin gives to the stool the 
characteristic green color. The green stools of infants may also be 
dependent upon the growth of such chromogenic bacteria as Bacillus 
pyocyaneus. 

The food residue has also much to do with the color of the stools. 
With a vegetable diet the stools are usually lighter in color than with a 
meat diet, whereas a milk diet produces a yellow or greenish-white stool. 
The coloring matter of certain fruits may give a dark-brown or greenish- 
black color to the feces, which without careful examination may be mis- 
taken for digested blood. 

Such discharges from the intestinal wall as mucus, pus, and serum 
rarely produce any definite coloration, though large quantities of mucus 
may impart a glassy or glistening appearance to the stool. Blood always 
changes the color of the stool if present in any quantity. The color 
depends much upon the length of time the blood has been in the intestines, 
and varies from bright red in fresh hemorrhages to a tarry black in old 
hemorrhages. 

Among the drugs, bismuth is the most important coloring agent. After 
the use of this drug the stools are colored gray or black from the presence 
of bismuth sulphide. 



EXAMINATION OF THE FECES 



29 



Small amounts of fat demonstrable microscopically either as neutral 
fat or as fatty acid crystals may appear in the stools in a number of condi- 
tions. Large amounts of fat in the form of fatty acid crystals give to the 
evacuation an exceedingly pale color^ while neutral fat may be present 
in such quantities that the stool is surrounded or covered with a yellow 
oily substance. 

When the flow of bile into the intestinal tract is cut off, a large per- 
centage of the ingested fat is not completely split up, and the stools may 
contain great quantities of fatty acid crystals (Fig. 2). When the 
absorption of fat is impeded by blocking of the intestinal lymphatics, 
such as may occur in tabes mesenterica, fat may also be present in the 
feces. A very important condition in which fatty stools may appear is 
disease of the pancreas. Fatty stools are by no means constantly seen 



Fig. 2 








-y^ 






X' 



4<- 



i 



A- 



-r 




if 

Forms of fats and soaps in stools (Sclimidt and Strassbuiger). a, soaps; b, casein and fat 
globules; c, fatty acid needles and leukocytes; d, yellow calcium soap; e, fatty acid crystals 
projecting from fat droplets; /, fatty acid and soap needles and scales from an acholic stool. 



in cases of chronic pancreatitis or in obstruction of the pancreatic duct, 
but they may occur, and the amount of fat may be large. Free fat may 
be passed in great amounts in chronic pancreatitis, surrounding the stool 
or covering it like melted butter. 

In alcoholics the stools may also be pale, due partly to the presence of 
fat, but principally to the transformation of the normal coloring matter, 
hydrobilirubin, into a colorless substance. 

Visible mucus may appear in the stool in various forms of catarrhal 
inflammation of the intestines. Typical long shreds, membrane-like 
pieces of mucus, or even casts of the intestines may be found in the stools 
in mucous colitis. Small glairy pieces of mucus are found in great 
amounts in diphtheritic dysentery and in amebic colitis. In both 
diphtheritic dysentery and amebic colitis the bowel movements may be 
composed almost exclusively of mucus, blood, leukocytes, and bacteria, 

The presence of blood in the stools points naturally to a hemorrhage. 
Large hemorrhages may come from bleeding hemorrhoids, newgrowths 



30 LABORATORY DtAGNOStS 

of the intestines, such as papilloma or carcinoma, and bleeding typhoid, 
or rarely tuberculous ulcers. Hemorrhages into the stomach caused by 
gastric ulcers, cirrhosis of the liver, or splenomegaly may be evidenced 
by the passage of copious bloody stools. 

By the newer methods of examination of the stools for occult blood, 
small quantities not recognizable by any other means may be detected 
and the presence of some form of ulceration of the gastro-intestinal 
tract determined. By this means it can be shown that the stools contain 
occult blood in many cases of typhoid fever, in ulcerations of the intes- 
tines due to intestinal parasites, in many acute inflammations of the 
intestinal tract, in ulcerating tumors of the large and small bowel, and in 
ulcers of the stomach. 

When an abscess ruptures into the intestinal tract, pus visible to the 
naked eye may be passed by the bowel. If the pus is evacuated into 
the bowel high up, it is usually mixed with feces, and when it is passed 
has undergone such alterations that it is rarely recognizable, except by 
the microscope. Great numbers of leukocytes may be found in the feces 
in various forms of intestinal ulceration, due to newgrowths, typhoid 
fever, or tuberculosis and amebic or bacillary dysentery. In acute forms 
of amebic dysentery, as well as bacillary dysentery, small masses of pus 
may be seen by the naked eye, mixed with mucus ot* blood. 

Occasionally small particles of a tumor are discovered in the feces, and 
when carcinoma of the intestines is suspected a careful search of the feces 
may show bits of tissue which on microscopic examination prove to be 
masses of newgrowth. If one is successful in finding such particles, the 
correct diagnosis can be arrived at with certainty. 

Gallstones, pancreatic stones, and intestinal stones are occasionally 
found in the feces. Since gallstones are quite frequently passed in the 
feces, an examination of the stools should be made in all cases of sus- 
pected cholelithiasis. The presence of cholesterin in a stone stamps it 
as coming from the gall-bladder. Pancreatic stones are rare. They 
may be identified by the fact that they are composed of calcium car- 
bonate. The enteroliths are formed principally of phosphates. 

Bacteriological examination of the stool is attended with many diffi- 
culties, though it may aid materially in the diagnosis of an intestinal 
disease. In typhoid fever, typhoid bacilli may be grown from the stools 
in quite a large proportion of, cases. It should be remembered that 
patients may continue to eliminate typhoid bacilli for months or years 
after an attack of typhoid fever. It is probable that in the chronic 
bacillus carriers the bacilli come really from the gall-bladder, which acts 
as a reservoir and allows of the entrance of innumerable typhoid bacilli 
into the intestinal contents. Tubercle bacilli are found in the stools of 
persons suffering with tuberculosis of the intestinal tract, but the 
finding of tubercle bacilli is not diagnostic of intestinal ulceration, since 
bacilli which have been swallowed with sputum may be found in the 
feces. 

In amebic dysentery the amebae are most numerous and most readily 
seen in bits of mucus. 



EXAMINATION OF THE SPUTUM 31 

The diagnosis of an infection of the intestines bv a parasite may be 
made solelv upon the discovery of ova of the parasite in the stool. In 

Fig. 3 



/i 



Eggs of parasites. Uncinaria americana. 



cases of anemia the stools should always be examined for parasites. The 
parasites which most commonly cause severe anemia are Ankylostoma 
duodenale, Bothriocephalus latus, and Paramecium coli (Fig. 3). 



EXAMINATION OF THE SPUTUM. 

An examination of the sputum may be of material benefit in assisting 
in the diagnosis of a few conditions which are treated by the surgeon, 
but is principally valuable in offering an aid to the better understanding 
of certain surgical complications. 

The quantity of the sputum may be quite small in many pulmonary 
conditions, but occasionally large amounts are expectorated in twenty- 
four hours. This is seen particularly in certain forms of chronic bron- 
chitis, in bronchorrhea, sometimes in pulmonary tuberculosis, in bron- 
chiectasis, gangrene and abscess of the lung, perforation of an empyema 
or of an amebic abscess into the bronchi, and with pulmonary hemor- 
rhage. 

The color of the sputum varies greatly according to the disease. In 
pneumonia, especially during the early stages, it has a rusty brown tinge. 
Sputum containing pus has a yellowish white or greenish tinge; when 
mixed with blood, it is red; and in jaundice it is yellow or green, due to 
the presence of bile pigments. In anthracosis the sputum is colored 
black or gray. The prune-juice sputum is typical of the discharge of an 
amebic abscess into the bronchi. 

The odor of the sputum in certain cases of pulmonary tuberculosis, in 
abscess and gangrene of the lung, and putrid bronchitis is extremely foul. 

Macroscopically one may distinguish mucus by its stringy, glairy 
appearance, and pus by its opaque yellowish or greenish look. Varying 
quantities of blood are seen in the sputum in pneumonia, in pulmonary 
tuberculosis, in heart disease, and in infarction of the lung. In the last 



32 



LABORATORY DIAGNOSIS 



two conditions large quantities of blood may be expectorated. In condi- 
tions such as abscess and gangrene small particles of lung tissue may 
be found which appear as white, green, or blackish particles. Cursch- 
man's spirals, readily visible to the naked eye, are present in cases 
of bronchial asthma. Fibrinous casts of the bronchi may be found in 
that condition known as fibrinous bronchitis. 

Microscopically the presence of many polymorphonuclear leukocytes 
gives evidence of an acute inflammation of the bronchi or alveoli. In 
bronchial asthma as many as 60 per cent, of the leukocytes may be 
eosinophilic. Red blood corpuscles may occur in many conditions. 
They may be found in the sputum in pneumonia, especially in the early 
stages, in heart disease, in infarction of the lung, in abscess, and in 
gangrene, and in pulmonary tuberculosis. Elastic fibers signify that 
alveoli or bronchi are being destroyed, and may be found in abscess, 
gangrene, bronchiectasis, and pulmonary tuberculosis (Fig. 4). 



Fig. 4 




Elastic tissue from lung. X 400. 



Charcot-Leyden crystals are seen in the sputum in bronchial asthma 
when they are found associated with the eosinophilic leukocytes. Fatty 
acid crystals are often seen in abscess and gangrene of the lung. 
More rarely leucin and tyrosin or hematoidin crystals are found. 

Two animal parasites are occasionally seen in the sputum. When 
an amebic abscess of the liver ruptures into the lung, amebse may be 
found in the sputum, and their discovery will clinch the diagnosis. In 
parasitic hemoptysis, ova of the lung fluke, or Distomum pulmonale, the 
parasite which causes the disease, is present in the expectoration. 

The presence of tubercle bacilli in the sputum means pulmonary 
tuberculosis, and naturally in every case suspected of having tubercu- 
losis the sputum should be searched most carefully for these bacteria. 
Repeated examinations in many instances are necessary to demonstrate 
their presence. 

The presence of great quantities of pneumococci in the sputum is 



EXAMINATION OF THE GASTRIC CONTENTS 33 

evidence of pneumonia or of some pneumococcal infection of the respira- 
tory tract. In influenza, both acute and chronic, the sputum may be 
loaded with influenza bacilli. A diagnosis of infection by this organism 
may be made from an examination of the sputum. Less frequently the 
Friedlander bacillus, Aspergillus fumigatus actinomyces, the glanders 
bacillus, and the bacillus of plague may be found in the sputum. No 
conclusions can be drawn from finding of the ordinary pyogenic cocci. 



EXAMINATION OF THE GASTRIC CONTENTS. 

Except for the information gained from a general or perhaps, in cases 
of poisoning, from a chemical examination of the vomitus, a study of 
this material gives but little definite knowledge concerning the main 
underlying disease. By general inspection one may determine whether 
the vomitus contains bile, blood, or undigested material. The odor will 
indicate roughly the presence of certain drugs or poisons, and a chemical 
analysis will yield accurate information. 

In the examination of the test meal we are especially anxious to know 
the total amount of acid, the amount of free hydrochloric acid, the amount 
of pepsin present, and as to whether lactic acid is or is not present. 

Under normal conditions, as the tests are carried out with the Ewald 
meal, the total amount of acid in the gastric juice varies between 30 to 
70 (0.11 to 0.26 per cent.), while the amount of free hydrochloric acid 
varies from 0.05 to 0.2 per cent. 

In a general way one may say that the total amount of acid is increased 
in gastric ulcer (in which condition the free hydrochloric acid is also 
increased), in simple hyperacidity, in certain nervous conditions, and in 
the early stages of chronic gastric catarrh. The acidity is decreased 
among other conditions in many anemic states, in certain gastric neuroses, 
in the later stages of chronic gastric catarrh, and in many cachexias. 
Free hydrochloric acid is found wanting in gastric cancer, in certain 
severe infectious diseases, in pernicious anemia, and in achylia gastrica. 

Lactic acid is found in carcinoma of the stomach, and combined with 
the lack of free hydrochloric acid, is very suggestive of this disease. 

The presence of occult blood in the test meal or in vomited material 
mav be significant of one of several conditions. Hemorrhage into the 
stomach may occur in gastric ulcer, carcinoma of the stomach, cirrhosis 
of the liver, or splenomegaly; but before one can draw any conclusions 
from the finding of occult blood, it is necessary to exclude with great 
care any admixture of blood from the mouth, gums, or from slight 
abrasions of the esophagus or gastric mucosa when the stomach tube is 
used. Of great importance is the examination of any small bits of 
tissue which may occasionally be found in the stomach washings. In 
cancer of the stomach, small particles of the tumor may be washed 
away during lavage, and by a microscopic examination. of these particles 
it is possible to establish the diagnosis of carcinoma. 

A microscopic examination of the test meal will reveal starch granules, 
3 



34 LABORATORY DIAGNOSIS 

a few epithelial cells, fat droplets, yeast fungi, and bacteria. The large 
bacteria, the Oppler-Boas bacilli, are associated with the presence of lac- 
tic acid in the stomach contents, and their presence suggests carcinoma. 
Both fresh and old blood may be seen, especially in carcinoma and gastric 
ulcer. Great numbers of leukocytes may be seen in certain cases of acute 
gastritis or when a carcinoma is breaking down and undergoing second- 
ary inflammatory changes. 

The presence of food eaten the day before the stomach is emptied 
by the tube points to retention which may be due to pyloric stenosis, 
gastroptosis, or dilatation. 

EXAMINATION OF TRANSUDATES, EXUDATES, AND SECRETIONS. 

Collections of transudated fluid removed from the pleura, the peri- 
cardium, and the peritoneum have much the same characteristics. They 
usually are clear yellow, of alkaline reaction, and contain albumin. In 
pleural transudates there may be many endothelial cells in the centrifu- 
galized sediment, but leukocytes are scarce or absent. A true transudate 
is always sterile. 

Inflammatory exudates vary in character according to the infecting 
agent which produces them. Exudates caused by the pneumocccus, 
the staphylococcus^ the typhoid bacillus, and the tubercle bacillus often 
present different characteristics. The exudate produced by the strep- 
tococcus, staphylococcus, pneumococcus, and sometimes by the typhoid 
bacillus is frankly purulent. The fluid is thick and white or yellow in 
color. Microscopic examination shows that by far the greatest number 
of cells are polymorphonuclear leukocytes, and smears stained in gentian 
violet will reveal the infecting microorganisms in great numbers. Some 
exudates due to the pneumococcus and typhoid bacillus are seropurulent 
or truly serous, containing comparatively few cells. If the specimen is 
centrifugalized, however, in the sediment it will be found that the cells 
which are present are of the polymorphonuclear variety. This is an 
important differential point in deciding as to whether a serous or sero- 
fibrinous exudate is tuberculous or not. 

Tuberculous exudates are almost always serofibrinous in character, 
though they may contain varying amounts of blood, while rarely the pres- 
ence of large quantities of cells gives them an opaque appearance. It 
is exceedingly difficult to demonstrate the tubercle bacillus in such exu- 
dates. The inoculation of animals will give positive results, and occa- 
sionally the method of examination designated inoscopy, in which the 
fibrinous coagulum is digested, the digested fluid centrifugalized, and the 
sediment stained for tubercle bacilli, will show the presence of bacilli. 
But a simpler method of differentiation is based upon the type of cell 
which is present in these exudates. It has been stated that in exudates 
caused by the pyogenic cocci, the polymorphonuclear leukocyte is the 
typical cell. In tuberculous exudates this cell is comparatively scarce, 
and the majority of elements are mononuclear cells. In tuberculous 
exudates 90 to 95 per cent, of the cells may be small mononuclears. 



EXAMINATIONS OF SECRETIONS 35 

True hemorrhagic exudates are seen principally in tuberculosis and 
carcinoma or sarcoma. Though a general carcinosis or sarcomatosis 
of the pleura or peritoneum may and often does give rise to hemorrhagic 
exudates, in certain cases the aspirated fluid may be serous in appearance. 
The presence of definite tumor cells in such exudates will lead to the 
correct diagnosis. 

The examination of the spinal fluid may be carried out in much the 
same manner as the examination of exudates from the pleura, pericardium, 
and peritonum. The spinal fluid from normal individuals contains only 
traces of albumin and but few cells, not more than 2 to 7 leukocytes per 
c.mm. The exudates are serous, serofibrinous, seropurulent, purulent, 
fibrinopirulent, or hemorrhagic. The meningococcus gives rise to a 
serous, seropurulent, or fibrinopurulent exudate. The characteristic 
cell is the polymorphonuclear leukocyte containing the infecting micro- 
organism. The meningococcus can be demonstrated in coverslips. The 
pyogenic cocci produce purulent exudates, and the typhoid bacillus 
usually serous exudates. 

In cases of tuberculous meningitis the spinal fluid is quite character- 
istic, and is serous, serofibrinous, or rarely seropurulent. The type of 
cell w^hich is found is the same as that seen in pleural or pericardial 
exudates — the small lymphocyte. But in the spinal fluid tubercle bacilli 
may be demonstrated in practically every case by an' examination of the 
filmy fibrin clot which forms in most fluids withdrawn from the meninges 
of cases of tuberculous meninoitis. 

For the Wasserman reaction in the diagnosis of syphilis, or the more 
recent reaction described by Xoguchi, the spinal fluid is even more useful 
than blood serum. The spinal fluids from 70 to 80 per cent, of cases of 
tabes and dementia paralytica give a positive reaction. 

It is almost impossible to draw any conclusions from the presence of 
blood in spinal fluid. Bloody fluids may be found in cases of cerebral 
hemorrhage, but it is so diflftcult to exclude blood which may be due to 
the puncture itself, that the withdrawal of bloody fluid from the spinal 
canal can have no significance. 



EXAMINATIONS OF SECRETIONS, FLUIDS FROM SCARIFIED 

SURFACES, ETC. 

The examination of any abnormal secretion will always be of some aid 
in determining the character of the pathological process. By the finding 
of gonococci in the urethral or vaginal discharges the diagnosis of 
gonorrhea can be made unhesitatingly (Fig. 5). In discharges from the 
ear, the eye, and the nose careful examination will determine the nature 
of the infecting organism, and if one desires to treat such chronic suppura- 
tive conditions with vaccines, it is positively essential that an accurate 
diagnosis of the infecting bacteria should be made, and that the vaccines 
should be prepared from growths of exactly the same organism which 
causes the trouble in that particular patient. By making smears from 



36 LABORATORY DIAGNOSIS 

an anthrax pustule the disease may be diagnosticated with certainty. 
The typical bacilli are often found in great numbers in coverslips. 

Since the discovery of the Spirocheta pallida a very valuable method is 
now at hand for the early diagnosis of cases of syphilis. The spiro- 
chetae are found in the chancre and in practically all the secondary lesions 
of syphilis (Plate III). To demonstrate these organisms, it is necessary 
to scarify superficially the surface of the chancre, mucous patch, condy- 
loma, or skin lesion, prepare coverslips from the exuding serum, which 
contains little or no blood, and stain by the method of Giemsa or 
Goldhorn, or by the newer silver method described by Stern. Smears 
may be prepared and stained in the same way from the aspirated juice 
of an enlarged lymph node. The spirochetse may be present in fairly 

Fig. 5 





1 


s 


:/ 




>•■ 


Gonococcus in pus cells. 


X 1 100 diameters. (Park.) 



large numbers, but frequently they are scarce and must be searched for 
with pains. If Spirocheta pallida can be demonstrated, the diagnosis 
of syphilis is assured. One must always use the greatest caution in 
differentiating Spirocheta pallida from Spirocheta refringens, which is 
frequently found in non-specific ulcers and erosions of the external 
genitalia. 

A method which is even more valuable, since it is more rapid, is to 
examine fresh material obtained in much the way as described above, 
under a microscope furnished with the new form of condenser that throws 
the rays from a powerful artificial light across the field of the microscope. 
With this transillumination the spirochetse appear as brilliant twisting 
spirals upon a black background. 



PLATE 111 



FIG. 1 



V 



o 



© ^ Q 



\^^^ 



Spirochaste Pallida. Smear from Hard Chancre. Giemsa's stain. 
X 1000. (Osier.) 



FIG. 2 




Spirochaste Refringens. Smear from Chancroid. X 1000. (Osier, 



CHAPTEE 11. 

THE APPLICATION OF THE X-RAYS IN SURGICAL DIAGNOSIS. 
By H. K. PANCOAST, M.D. 

The maximum efficiency of the x-Ta.ys is attained and the minimum 
danger incurred only when the apparatus is thoroughly modern and 
skilfully handled and the results are interpreted by one familiar with 
its workings and trained by a large experience to recognize the correct 
meaning of the different shadows. 

With very few exceptions the skiagraph ic examination is preferable to 
that by the fluoroscope. The latter, even in the hands of those expert 
in its interpretations, is often misleading. 

The risks involved in the radiographic examination are now so slight 
that they may be practically disregarded. 

BONES AND JOINTS. 

The interpretation of radiographs taken for the detection of affections 
of the bones and joints involves a knowledge of the normal appearances 
and variations in conformation of bones and joints and a clear conception 
of epiphyseal development and union in relation to age. 

Fractures. — When the ordinary and diagnostic sjinptoms of fracture 
are present, the a:-rays are serviceable in accurately determining the nature 
and extent of the deformity, the interposition of soft parts, the presence 
or absence of comminution, or the antecedent pathological condition 
predisposing to a break. 

^Vhen the usual signs of fracture are indistinct, or cannot be elicited 
because of tenderness and great swelling, the a:-ray examination is indis- 
pensable. Under this heading may be classed most incomplete and 
impacted fractures, all those lying in the joint or near it, fractures of the 
carpal bones and proximal ends of the metacarpals, of the tarsals and 
metatarsals. 

Examination of a patient suffering from injury in the neighborhood 
of a joint cannot be regarded as complete until it has been supplemented 
by the information gained by the skiagraph. Many of the bone lesions 
cannot possibly be diagnosticated in any other way, and in some, as 
instanced by an impacted fracture of the femoral neck, manual diag- 
nostic efforts are distinctly contra-indicated. 

The a;-rays give, without pain or added tramna, complete information 
in regard to the presence of fracture, its seat, its nature, and the direction 
and degree of deformity. 



38 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

When a skiagraph is taken for diagnostic purposes, all dressings should 
be removed, if this be practicable, since all are obscuring to an extent, 
and some unexpectedly so to the inexperienced. Thus, lead water, bichlor- 
ide of mercury solution, iodoform, ointments containing metallic salts, 
starch bandages, and plaster all interfere with the production of clear 
pictures. Nevertheless, the best interests of the patient may require a 
picture to be taken under circumstances other than those most favorable. 
Though clear definition is essential to the determination of certain 
bone lesions, it is not usually required in the gross diagnosis of fracture. 

In cases of fracture without adequate cause the x-rsijs afford the only 
means of framing a diagnosis of the underlying bone affection, as, for 
example, cyst, central sarcoma, or chronic osteomyelitis. 

In cases of delayed union or non-union with inconclusive clinical 
symptoms, the :r-rays are diagnostic, showing the presence or absence of 
bony callus between or around the ends of the fragments. As lime salts 
are practically absent in fibrous union, there will be no shadow, such as 
that cast by bone in the process formation. Moreover, the skiagram 
will often show the cause of non-union. 

For the purpose of affording protection to the physician who first sees 
a case of injury about a joint which may be associated with fracture 
of the bone, a skiagraphic record is of cardinal importance, since subse- 
quent disability, common even in bone injuries properly treated, is inevit- 
ably attributed by the patient to negligence on the part of his physician. 
If an x-YSij picture taken during this period of continued crippling and, 
sometimes, well-founded discontent exhibits a deformity or a chronic 
arthritis incident to an unrecognized fracture, the patient will probably 
find twelve of his peers convinced by such a picture of his right to redress. 
Nor will the profession at large consider that the patient's interests have 
been intelligently conserved by the doctor who has failed to utilize the 
only means by which an accurate diagnosis can be made. 

As to the method of examination, whenever possible the plate should 
be taken from at least two directions, the exposures being at right angles 
to each other, or nearly so. A single good picture may entirely fail to 
show a fracture in which there are obvious deformity and crepitus. The 
regions in which single view pictures have been most misleading are the 
elbow, the wrist, the knee, and the ankle. Oblique fractures of the long 
bones, even with obvious deformity, occasionally give in a single view 
picture the appearance of complete continuity. 

In some regions it is impossible to take pictures from two directions 
and in others it is extremely difficult. The region of the shoulder and 
upper portion of the humerus can be skiagraphed in the anteroposterior 
direction only. When the elbow is dressed in a flexed position, the 
lateral view alone is possible. The pelvis and most of the spine cannot 
be satisfactorily examined laterally. The upper six cervical vertebrae 
can be, however, and the picture thus afforded is usually much more 
satisfactory than the anteroposterior one. Lateral views of the hips and 
the upper portion of the femoral shaft are impossible. 

Both anteroposterior and lateral radiographs are important in demon- 



BONES AND JOINTS 39 

strating fractures of the humeral condyles. The lateral picture best 
shows injuries of the olecranon and the coronoid process, and supra- 
condyloid fractures. The side view is the essential one for all fractures 
of the patella, os calcis, and astragalus. 

It should be a general rule to make comparative radiographs of the 
bones and joints of the healthy side unless the diagnosis is obvious. This 
is especially important in the joint lesions of young people. 

The direction of the two vicAvs taken should be as nearly as possible 
in the same plane and at right angles to each other, and the tube should 
be placed as nearly as possible over the seat of injury. If the source of 
rays be unintentionally or carelessly so placed as to throw distorting 
shadows, marked deformity may appear in the plate when it does not 
exist in fact. 

Epiphyseal Separations.— These injuries will not show in the skiagraph 
unless there be associated bone lesion or pronounced displacement. 
The evidence obtained by comparative pictures of corresponding portions 
of the opposite side is often at least suggestive. Negative results in 
these cases are not conclusive. 

Fracture of the ossified epiphysis or extension from the diaphysis 
into the epiphyseal line, with or without epiphyseal separation, is, how- 
ever, readily shown. 

Inflammations. — Acute suppurative periosteitis, osteomyelitis, and 
epiphysitis should be recognized by the clinical symptoms and receive 
proper treatment before the bone changes are sufficiently pronounced to 
produce a characteristic x-yslj picture. 

Chronic Osteomyelitis. — In chronic osteomyelitis necrosed bone throws 
a less dense shadow than the surrounding structure. The sequestrum, 
when separated, appears as a loose fragment surrounded by a clear area 
representing the cavity in which the dead bone lies. The shadow of an 
involucrum will be shown as soon as the deposition of lime salts begins. 

In pyogenic osteomyelitis chronic from the start, with the process 
comparatively extensive, the shadow of the affected portion of the bone, 
which is the seat of a rarefied osteitis, will appear decidedly less dense 
in the skiagraph than that of the surrounding osseous structure in which 
both condensation and thickening are likely to have taken place. This 
condition of rarefied osteitis must not be confused with the appearance 
observed in the cancellous ends of bones near joints exhibiting lesions of 
chronic arthritis, or the similar appearance developed after prolonged 
fixation of the joint, such, for instance, as is needful in the treatment 
of fracture. 

In the type of chronic osteomyelitis characterized by local abscess 
formation, often termed Brodie's abscess, and located in the upper ex- 
tremity of the tibia, the lesion can usually be readily detected and accu- 
rately localized by means of a radiograph (Fig. 6) . 

Tuberculosis. — Tuberculosis can be detected as soon as bone disinte- 
gration has progressed far enough to cause an appreciable difference in 
the density of the shadow of the affected portion. Hence, as the process 
of caseation and softening is essentially slow, the diagnosis as to the seat 



40 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

of disease and its extent can be made by the x-tslj before softening has 
taken place, and at the time when cHnical diagnosis is more or less 
uncertain. 

The accurate localization of the seat of invasion is of cardinal impor- 
tance from the standpoint of treatment. In tuberculous disease involving 
the carpus and tarsus, the skiagraph will show whether it is distinctly 
limited to one of the small bones, as an osteitis, or to the joint structure, 
as an arthritis; or whether the disease is more widespread. 

In the late stages of tuberculous infiltration characterized by exten- 
sive osteomyelitis, with necrosis, the a;-ray picture, while showing the 
lesion, in no way indicates its tuberculous nature. 

Fig. 6 




Superficial "Brodie's abscess" head of tibia of raale, aged twenty years. Radiograph 
indicates exact location of lesion. 

Syphilis. — In addition to the demonstration of the seat, nature, and 
extent of the syphilitic bone invasion, the skiagraph has a distinct diag- 
nostic value in that it may identify the lesion as one of syphilis, and, 
moreover, may picture the traces of former lesions of a similar nature. 

There are two distinctly different appearances found in the skiagraphs 
of bone lesions of acquired syphilis, dependent upon whether the process 
is essentially one of destruction or of proliferation. 

In the typically active lesion, the periosteal gumma, there will be shown 
a shadow of the swollen periosteum and usually of the soft parts as well. 
Later, the evidence of osseous degeneration is afforded by a roughened 
surface indicating a superficial caries or a deeper or more extensive area 



BONES AND JOINTS 



41 



of distinctly rarefied or even necrosed bone. Necrosis is unusual, since 
one of the most characteristic features of syphilis is that a large portion 
or even the entire shaft of the long bone may become extremely rarefied 
without actual necrosis taking place. 

As in all other chronic bone inflammations, there is an accompanying 
condensation of the surrounding structure, the shadow of the bone 
immediately around the localized lesion appearing denser than normal 
in the later stages of the affection. This proliferative process'is especially 
evident on the surface (Fig. 7), and the subperiosteal new bone forma- 
tion will be observed in the form of nodes and osteophytes in the case of 
localized lesions, or of a considerable general thickening if the process be 
extensive. 

Fig. 7 




Syphilitic osteomyelitis involving nearly entire shaft of ulna in a girl, aged sixteen years. 
Note coincident rarefying osteitis and subperiosteal newgrowth. 

The distinction between chronic syphilitic osteomyelitis and that 
due to other infecting agents is based mainly on the extensive rarefac- 
tion and the superficial thickening without necrosis. 

Bone sarcoma in its usual form resembles syphilis only in its earliest 
stage. The less malignant and less common type of sarcoma, associated 
with more or less new bone formation, may sometimes lead to error, 
though the bone formation produces an appearance quite unlike that 
characteristic of syphilis. Periosteal sarcomas are more likely to lead 
to mistake from the a;-ray standpoint, since the appearances they present 
are not uniformly so typical as those shown by the central growths. 



42 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

Osteitis deformans, which may present a picture closely resembling 
that of syphilis, is rarely accompanied by the superficial localized bony 
outgrowths observed in the latter disease. 

Post-typhoidal osteitis may resemble the early stage of gumma, but 
the raised periosteum is but little thickened, nor is the surrounding osseous 
structure markedly condensed. 

In hereditary syphilis the skiagram is less characteristic. Usually the 
seat of the osseous lesions aside from dactylitis is at the epiphyseal junc- 
tion with the bone shaft, a locality in which an x-ray examination is 
unsatisfactory during infancy. Serration, irregularity, and broadening 
of the diaphysis where it joins the cartilage, or enlargement of its entire 
extremity, accompanied by sclerosis and condensation, may be shown. 
A similar appearance may be seen in rickets, but here the widening 
is closely limited to the extreme end of the diaphysis and is not accom- 
panied by sclerosis or serration. 

In syphilitic dactylitis the diaphysis is greatly thickened throughout, 
or there is more or less widespread necrosis, with perhaps a tendency to 
the formation of an enveloping involucrum. 

Miscellaneous Pathological Conditions Peculiar to Bones. — 
Osteitis Deformans. — The characteristic skiagraphic features of this 
condition are the uniform enlargement of a large portion or the entire 
shaft of the affected long bone or bones, accompanied by a marked 
condensation or sclerosis of the compact structure. At first the thick- 
ening is especially noticeable as involving the compact portion, and 
it may encroach upon the medullary canal. The latter, however, is 
usually rendered more perceptible through contrast with the extreme 
density of the compact structure. The medullary cavity obviously 
shares in the enlargement in some instances. Occasionally, when the 
bones have assumed tremendous proportions, in late stages of the disease, 
the central cavity has undergone an extreme degree of hypertrophy, 
even surpassing that of the compact structure, accompanied by enormous 
thickening of the normally thin walls. This process involves the can- 
cellous ends as well, and the correspondingly enlarged medullary spaces 
give to the entire bone somewhat of a multilocular cystic appearance. 
At almost any stage of the disease the skiagraphic appearance is usually 
sufficiently characteristic for diagnosis of the condition. 

Acromegaly. — The skiagraphic picture of the bones in this condition 
shows nothing but uniform hypertrophy. 

Achondroplasia. — The skiagraph shows the typical appearance of the 
long bones — the abnormally short and slender diaphyses or shafts and 
the relatively large epiphyses or ends, which are, however, actually nor- 
mal or nearly so in size and development, while the shafts are deficient. 

Fragilitas Ossium. — The most noticeable skiagraphic feature in this 
condition is the extremely rarefied appearance of the long bones, especially 
at their extremities, arising from the imperfect ossification of the bone 
trabeculse characteristic of the disease. The extreme rarefaction extends 
into the shafts far beyond the normal limits, showing the reason for the 
frequency of fractures. 



BONES AND JOINTS 



43 



Rickets. — The skiagraph has Httle value in the examination of the bones 
during the active stage of this disease. 

In connection with the deformities arising from the disease, especially 
from the standpoint of the surgeon, the skiagraph is of great value, since 
the exact seat and extent of deformity can then be determined. After 
the application of the retentive dressing it is an easy means of deter- 
mining whether the proper relations have been preserved. The nature 
and extent of rachitic deformities of the pelvis in pregnant women can 
readily be demonstrated by the x-ysljs. 



Fig. 




Osteosarcoma of shaft of tibia in male, aged twenty-five years. 

of previous osteoma. 



Sarcomatous degeneration 



Tumors of Bone. — The appearance of each of the more common 
tumors is sufficiently characteristic to make the x-ray examination a 
fairly reliable means of determining the exact nature and the origin and 
seat of the growth. 

Sarcoma. — In the periosteal form the skiagraphic appearance is not 
so distinctly characteristic as in the central variety. If the diagnosis of 
sarcoma is fairly well assured, the skiagraph will easily determine which 
of these two varieties is present (Fig. 8). 



44 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

In the early stage of a periosteal growth its shadow will probably be 
in evidence, but there is nothing typical in the slight bony destruction 
accompanying the round-cell type, and the appearance may be more 
or less confusing. The skiagraph cannot always be accurately inter- 
preted by itself, but must be studied in connection with the clinical data. 

In the semimalignant types of osteosarcoma the appearance is usually 
characterized by the evidence of new bone formation, together with more 
or less bony destruction. There is considerable variation to be noted 
in the appearances in different cases, and, although they are usually 
characteristic, some experience is required to interpret correctly the 
skiagraphs of these less common growths (Fig. 9). 

Fig. 9 




Osteosarcoma — semimalignant or giant-cell type — of calcis of female, aged forty-seven years. 
Note new bone formation in contrast with complete bone destruction shown in more malignant 
form (Fig. 10). 

In the malignant round-cell central osteosarcomata the appearance 
is invariably characteristic, except in the early stages of the growth, 
when it may be confused with a bone cyst or a syphilitic osteitis. After 
the growth has reached an appreciable size, however, the appearance 
of this type cannot readily be mistaken (Fig. 10). 

Bone Cysts. — ^The skiagraphic appearance of this condition closely 
resembles that of central sarcoma. Although there are some points of 
distinction, the diagnosis by the x-ray examination alone is difficult 



BONES AND JOINTS 



45 



and sometimes impossible. A knowledge of the clinical history of the 
case is very important in interpreting the skiagraph. Bone cysts are 
comparatively rare, however. 

Osteoma. — The skiagraph readily establishes the nature of these 
tumors, together with their size, location, and anatomical relations, 
especially in connection with neighboring joints. There is a type of 
osteoma which bears some resemblance to sarcoma, and through lack 
of experience it may be mistaken for the latter (Fig. 11). 

Fig. 10 




Typical osteosarcoma of lower end of radius in adult female. 



Enchondroma. — The shadow is faint and lacks any characteristic 
details, owing to the homogeneous structure of the growth and the 
slight difference in density between it and the surrounding soft struc- 
tures. The a:-ray diagnosis is usually more one by exclusion than a 
direct one. 

Carcinoma. — In this condition the value of the skiagraph depends to a 
great extent upon whether the bone is involved by contiguity or by metas- 
tasis. In the former instance the examination will show, first, whether 
the bone is involved or not, and secondly, the extent of involvement. 
Metastatic carcinoma of bone has no special skiagraphic feature of its 



46 1'HE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

own, and the diagnosis must usually be made with the assistance of the 
clinical data. 

Injuries and Surgical Affections of the Joints. — Dislocations. — The 
diagnosis of the majority of dislocations, especially those of the larger 
joints, can be made without the assistance of the skiagraph, but that it 
is not always done is shown by the comparatively large number of old 
unrecognized unreduced dislocations seen by the o^-ray specialist. The 
radiograph will show the displacement and will prove the completeness 



Fig. 11 




Osteoma of humerus in 



female, aged thirteen years. Appearance not unlike that of 
sarcoma in some respects. 



or incompleteness of reduction, but its main value lies in the detection 
of complicating fractures. All luxations should be so examined whether 
satisfactory reduction has been accomplished or not. 

Such fractures are apt to extend into the joint, and they may be over- 
looked because of the greater prominence of the manifestations of the 
dislocation, or because they are obscured by swelling, or because they are 
of such types as are naturally difficult to diagnosticate clinically. Their 
detection is important and a routine x-tslj examination of all cases of 



BONES AND JOINTS 47 

dislocation, either before or after reduction, is the most rehable means 
of avoiding otherwise inexcusable mistakes which are likely to result in 
disability and discomfort to the patient and to reflect discredit upon the 
one who treats him. 

In children dislocations are sometimes mistaken for epiphyseal separa- 
tions, and vice versa, but the skiagraph will nearly always reveal the 
exact condition which exists, although extreme care in taking the picture 
and a certain amount of experience are often essential for correct inter- 
pretation of the plates. 

The common dislocations of the shoulder- joint are rarely difficult to 
diagnosticate clinically, although old unreduced ones are frequently met 
with. It should be borne in mind, however, that they are often compli- 
cated by fractures, usually of the surgical neck of the humerus, rarely 
of the anatomical neck, or other less common fractures. In children this 
dislocation may be associated with separation of the upper epiphysis of 
the humerus. An x-tslY examination of a shoulder is advisable after 
reduction, because in some instances reduction is found to be incomplete 
even when it has apparently been satisfactorily performed. The com- 
paratively rare subspinous dislocation is rather difficult to demonstrate 
with absolute certainty in the skiagraph. These same remarks are 
applicable in connection with acromioclavicular dislocations, although 
the latter are usually less difficult to detect. 

Fractures of either the clavicle or the acromion in close proximity to 
this joint are sometimes very difficult to distinguish from dislocations 
except by means of the skiagraph. 

By far the greatest number of serious mistakes in diagnosis of disloca- 
tions are made in connection with those at the elbow-joint, either in failure 
to detect the presence of this injury or of one or more complicating frac- 
tures, or both. The skiagraph shows that dislocations at this joint are 
complicated by fractures in a large percentage of cases. 

A careful skiagraphic study of injuries of the wrist shows that disloca- 
tions of the carpal bones are far more common than was formerly supposed. 
Luxations of one or more of these bones may occur independently, but 
they are usually associated with fractures of the bones of the forearm, 
which, by the greater prominence of their manifestations, are apt to divert 
attention from the possibility or even the evidence of the former injury. 
Some of these fracture-dislocations of the wrist are complicated. Blows 
on the wrist by automobile cranks have become a frequent cause of 
such injuries. 

Carpal dislocations are difficult to diagnosticate clinically, and, even in 
the skiagraph, a dislocation of one or more of the bones may be over- 
looked unless pictures of the opposite wrist are made for comparison. 

Traumatic dislocations of the hip do not usually require a:-ray examina- 
tion for their detection, but there is always the possibility of compli- 
cating fractures in these cases, especially of the rim of the acetabulum. 
In connection with congenital hip dislocations, the skiagraph is important 
as a means of diagnosis alone; it is also of great value in determining the 
extent of development of the acetabulum and the head and neck of the 



48 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

femur, and, in this way, of showing to a certain extent the possibihties 
of obtaining a successful result in treatment. It may also offer some sug 
gestions as to the best method of treatment (Figs. 12 and 13). 

Fig. 12 




Congenital dislocation of left hip in a boy, aged seven years. Note lack of development 
of acetabulum and head, and formation of new socket. 

• Fig. 13 




Congenital dislocation of left hip in a child, aged two years. Note lack of development 

of acetabulum. 



BONES AND JOINTS 49 

The x-rsij examination has now come to play an essential part in the 
treatment of these cases. It is the only accurate means of determining 
the measure of success in reduction and the relation of the head of the 
femur with the acetabulum after the application of the retentive dressings, 
especially as the latter are employed in connection with the after-treat- 
ment of the ''bloodless" methods of reduction. The examinations can 
usually be made through the casts if the removal of the latter is not 
desirable. 

Dislocations of the tarsus are not so frequent as are those of the wrist 
and carpus, but their detection by manual examination may be equally 
difficult, and the nature of the injury may not be readily or accurately 
determined without the assistance of the skiagraph. Subluxations in 
which a comparatively slight amount of displacement is permitted by 
the torn or stretched interosseous ligaments are of somewhat frequent 
occurrence, as is shown by the skiagraph, but their detection by other 
means is usually difficult or impossible. 

Arthritis. — A discussion of the value of a;-ray diagnosis in connection 
with the various forms of joint inflammation renders it necessary to 
follow some appropriate classification of the different types of arthritis, 
in the light of our more recent knowledge concerning certain distinguish- 
ing features to be observed in the radiographic appearance characteristic 
of each one. The classification here employed does not differ materially 
from the one which is now coming into use by many authorities, and is as 
follows : 

1. Acute arthritis: 

(a) Septic. 

(b) Infectious, acute suppurative type. 

(c) Acute articular rheumatism. 

2. Chronic tuberculous arthritis. 

3. Chronic non-tuberculous arthritis: 

(a) Atrophic type. 
(6) Hypertrophic type. 

(c) Infectious type. 

(d) Gouty arthritis. 

4. Arthropathies. 

1. Acute Arthritis. In either the septic, infectious, or rheumatic form 
the skiagram is of little or no diagnostic value in the early stage before 
the destructive process has advanced to any appreciable extent. The 
diagnosis by other means is, however, usually obvious. - At a later 
stage, after erosion of the articular surfaces or more extensive destruction 
of bone has taken place, the skiagraph can be relied upon to indicate 
such changes, and also their extent and exact locality. 

2. Chronic Tuberculous Arthritis. This being a slow and at the same 
time progressively destructive process makes it possible to detect the 
existence of the disease and to determine the locality of the focus at a 
relatively early stage. 

All of the chronic forms of arthritis present more or less characteristic 
skiagraphic appearances, but the a;-ray diagnosis is particularly important 
4 



50 T'ltE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

in this form, because it is invariably reliable and will show the presence of 
the disease at an early period, often before the clinical diagnosis can be 
settled with certainty. A negative rr-ray diagnosis should not be accepted 
as final in the incipient stages of the affection. As soon as the process 
has involved the bony structure to any appreciable extent, the resulting 
erosion of the articular surfaces in a case of primary arthritis is easily 
demonstrable. The primary focus of the disease lies often in an adja- 
cent epiphysis or just beyond the epiphyseal line. The location of such 
a focus can be made with certainty only by the ic-rays (Figs. 14 and 15). 
In hip-joint disease the diagnosis can be made by means of the skia- 
graph at a comparatively early period. In advanced cases x-ray findings 
serve as useful guides in determining the form and extent of surgical 
intervention. 

Fig. 14 




Tuberculous abscess of lower end of diaphysis of radius in a child, aged six years. 
Radiograph indicates exact location and extent of lesion. 

3. Chronic Non-tuberculous Arthritis. — Atrophic Type. — This type is 
characterized by slow progress with subacute exacerbations, and, observed 
in ill-nourished adults of low vitality. It usually affects first the joints 
of the hands and wrists. The radiographic features of this type are: 
(a) Absorption and erosion of the articular cartilages, represented in 
the skiagraph by an abnormally close approximation of the articular 
surfaces of the bones; (b) erosion of the articular surfaces of the bones, 
readily demonstrable radiographically; and (c) rarefaction of the can- 
cellous structure, which is in a measure a part of the atrophic process 
and partly an atrophy of disuse. 

Hypertrophic Type. — This type is observed most frequently in later 
adult life, usually in active individuals who are apparently otherwise 
healthy and well nourished. The course of the disease is usually more 
gradual; exacerbations may be observed, but are usually slight or wanting. 
The joints of the hands and wrists are first affected, the term "Heberden's 
nodes" being applied to the swellings due to the hypertrophies, but the 
disease is manifest in the larger joints quite as frequently, particularly 



BONES AND JOINTS 



51 



the knees and hips. It is frequently monarticular clinically, especially 
in the case of the large joints, but skiagraphic evidence of the disease 
is very often found on the opposite and apparently healthy side. The 
radiographic features of this type are: (a) Absorption and erosion of 
the articular cartilages; (b) characteristic hypertrophy of the bones near 
the articular surfaces; and (c) more or less condensation of the cancellous 

Fig. 15 




Tuberculous osteomyelitis and epiphysitis of lower ends of tibia and fibula of a child, aged 
four years. Radiograph indicates exact location and extent of process. 



structure, although rarefaction is apt to predominate as a part of the 
coincident atrophy of disuse. 

The typical picture is not always found in these cases, as the process 
of atrophy often accompanies that of hypertrophy. Evidences of absorp- 
tion and erosion of cartilage are more apt to be observed than of hyper- 
trophy, and erosion of the articular surfaces of the bones is often found 
associated with the excessive deposits outside. 



52 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

Infectious Type. — Broadly speaking, this type includes all chronic 
non-tuberculous joint manifestations not conforming to either of the two 
preceding types, and not of gouty origin. From the etiological point of 
view, the term applies to all chronic joint manifestations associated as 
complications or sequelae with gonorrhea, pneumonia, many of the acute 
infectious fevers, and such joint disturbances as are referable to various 
toxemias arising from altered metabolism and other sources. The joint 
condition into which acute articular rheumatism lapses often conforms 
to this type. 

Fig. 16 




Case of supposed metatarsalgia in adult female. Note exostosis on second metatarsal, 
causing pain by nerve pressure. 



The process in some of these joint complications may be acute and 
go on rapidly to suppuration, but this is the exception. The great 
majority of these manifestations are essentially of a chronic nature, and 
the prominent clinical features are more or less pain, tenderness, and 
disability, associated with articular and periarticular swelling, and per- 
haps atrophy due to disuse. 

The radiographic features of this type are: (a) The entire absence of 
hypertrophy of the ends of the bones and of atrophy of their articular 
surfaces; (6) often more or less absorption of the articular cartilages, 
shown in the skiagraph by the closer approximation of the bones, but not 
usually an erosion; (c) evidences very often of articular swelling due to 
effusion, and of periarticular swelling made evident by thickening of 
the capsule and other periarticular structures; and (d) a rarefaction 
of the cancellous structure, corresponding, in part at least, to a local 
atrophy of disuse. 



BONES AND JOINTS 



53 



It will be noted that the essential difference between this type and the 
two preceding ones is the absence of any distinct articular lesions. 

Gouty Arthritis. — ^The characteristic joint manifestations of gout as 
revealed in the skiagraph make this form of arthritis a distinct type in 
itself. The special radiographic features are the early destruction of 
bone and the actual disappearance of the cancellous trabeculae of the 
ends. The process may involve the shafts of the short long bones as well. 
The appearance often somewhat resembles that of central osteosarcoma. 
Evidence is also to be found, of course, of erosion of the articular sur- 
faces. The tophi are to be included in the periarticular swellings, but 
they do not cast characteristic shadows. 



Fig. 17 




Spur on under surface of os calcis in female, aged sixty years. Radiograph made for suspected 
piece of needle, but shows spur to be the cause of pain. 



4. Arthropathies. — ^These present skiagraphic findings in accordance 
with the nature and cause of the pathological process. There is nothing 
distinctive in the appearance of the joint manifestations of underlying 
nerve lesions. 

Loose Bodies. — ^The presence of loose bodies in joints can be detected 
by means of the radiograph, provided their structure is of sufficient 
density to cast perceptible shadows. 

The knee is the joint involved in the great majority of instances, and 
a detached or movable semilunar cartilage is the offending body in per- 
haps the majority of cases. The skiagraph is of value only in so far 
as it excludes other conditions. 

The presence of small detached fragments of bone, calcified synovial 



54 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

fringes with or without attachment by a pedicle, and sometimes even rice 
bodies, can be satisfactorily demonstrated. 

Bunion. — ^The x-rays are at times useful in showing the presence of de- 
structive inflammatory processes in the bones or the joint. They are also 
helpful in suggesting a form of surgical intervention when this is needful. 

Orthopedic Conditions. — Orthopedic conditions, especially cervical rib, 
congenital dislocations of the hip, coxa vara, scoliosis, genu varum and 
valgum, and congenital malformations and deficiencies, present a wide 
field for x-ray diagnosis, and in many instances it is essential in deter- 
mining the exact nature, seat, and extent of the condition. 



INJURIES AND SURGICAL AFFECTIONS OF THE HEAD. 

Foreign Bodies. — The examination for foreign bodies in the head 
requires special mention because of the serious disturbances they may 
provoke, the necessity of their removal in so many instances, the compara- 
tive frequency of gunshot injuries in this part of the body, and the im- 
portance of accurate localization by means of special apparatus requiring 
special methods. In the large majority of cases it is necessary to deter- 
mine the exact location of bullets, whether lodged within or outside of 
the cranial cavity, first, in order to determine the advisability of extrac- 
tion or whether the body is accessible or not; secondly, accurate locali- 
zation simplifies the operation for removal by indicating the easiest and 
safest avenue of approach. Such special methods should always be 
employed if accuracy is desirable, as the crude method of localization 
by making two pictures in opposite directions is not sufficiently reliable, 
and in fact may be very misleading. 

In the eye and orbit foreign bodies may be localized with unusual 
accuracy, and an examination is practically imperative in most instances. 
There are a few important sources of error to be avoided, but such 
examinations must be made with care and by competent persons. The 
detection of a foreign body in the orbit depends upon the density of the 
substance. Small fragments of superior qualities of glass, as from the 
lenses of spectacles, splinters of wood, and other less dense substances, 
may not cast shadows, and their presence, therefore, may not be detected. 
Hence, negative x-ray diagnosis in such instances is not always conclusive. 

The Nose and Accessory Sinuses. — It is possible to secure excellent 
details of the accessory sinuses, especially by means of the stereoscopic 
method. Important data may be derived from the x-ray examination 
of the frontal sinuses — their size, shape, the extent of their development, 
the number of subdivisions or the septa dividing them, and whether 
they are symmetrical on both sides. In addition, the presence of pus and 
even any considerable degree of thickening of the lining mucous mem- 
brane can be determined with uniform accuracy. The radiograph is, 
therefore, a valuable means of diagnosis of disease of these cavities and 
is far superior to transillumination. The skiagraph is equally reliable 
and useful for the detection of disease and newgrowths of the antra. 



INJURIES AND SURGICAL AFFECTIONS OF THE HEAD 55 

Although it has always been possible to radiograph the frontal and 
ethmoidal sinuses and the antra laterally, it is only since anteroposterior 
and stereoscopic views have become practicable that we have been able 
to obtain uniformly reliable and useful data. The anterior ethmoid 
sinuses may be examined in the fore-and-aft direction, but the stereo- 
scopic method shows them to much better advantage. The sphenoid 
and posterior ethmoid sinuses can be clearly shown stereoscopically, but 
they cannot be satisfactorily examined otherwise. 

Disease (caries and necrosis) of the bony walls of all of these cavities 
can be detected with reasonable accuracy, as can also the presence and 
the extent of newgrowths. 

Tumors. — Tumors involving the bones of the skull are mainly recog- 
nizable by the presence of either destruction or formation of bone. Osteo- 
mata may usually be detected by the application of proper methods of 
examination. Destructive tumors, such as sarcomata involving the 
cranial vault or base of the skull, may also be detected and studied 
under favorable conditions. 

When tumors involve the lower jaw the skiagraphic evidence is posi- 
tive and reliable. 

In connection with brain tumors, recent advances, especially in the 
stereoscopic method, have made it possible to obtain valuable informa- 
tion in some instances, although the .r-rays are not often dependable for 
diagnosis. 

Dental Radiography. — Many of the abnormalities and pathological 
conditions in connection with the teeth and surrounding structures 
that were formerly exceedingly difficult or even impossible to determine 
with certainty are now clearly and accurately demonstrated by the 
skiagraph. Some of these conditions can be determined in no other 
way. Among them may be mentioned the presence of unerupted and 
impacted teeth, supernumerary unerupted teeth, absence of teeth not 
erupted, deformities and exostoses of roots causing symptoms or complica- 
ting extraction, abnormal relations of any of the upper set with the antra, 
presence of foreign bodies, such as broken pieces of instruments in the 
root canals or beyond the apices, fillings in the root canals, and calcifi- 
cation of the pulp or ''pulp stones." The skiagraph is the only certain 
means of diagnosticating dentigerous cysts. 

The ic-ray examination is of considerable value in the diagnosis of 
diseases of the surrounding structures, such as alveolar abscess and 
necrosis and pericementitis, and is often useful in showing the relations 
of the roots in cases in which irregularities of the teeth exist and in which 
correction is indicated. It is also important in showing the relations 
of teeth to fractures, especially of the lower jaw. 

Salivary Calculus. — The detection of calculi in the duct of the parotid 
gland is not difficult, but Wharton's duct is overshadowed by the lower 
jaw, and shadows of calculi in this duct are rather difficult to differentiate, 
although the x-raj diagnosis can be made. 



56 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

INJURIES AND SURGICAL AFFECTIONS OF THE THORAX AND 
THORACIC VISCERA. 

In the examination of the chest, the x-rsijs have a wider apphcation 
in connection with the diagnosis of medical than of surgical conditions. 
This is largely because the number of injuries involving this part of the 
body is relatively small and the majority of disease conditions affecting 
the thoracic organs are distinctly medical in respect to their treatment. 

The Ribs. — Fractures. — X-ray examinations are made less frequently 
for fractures of the ribs, perhaps, than for fractures of any other bones 
of the body except those of the skull. There is no particular reason why 
the skiagraph should not be more often employed in this connection, 
but the failure to use this method more extensively probably arises from 
the tendency to regard its practical diagnostic value as incommensurate 
with the difficulty, trouble, and expense involved in such examinations. 
In the majority of instances fractures occur in those portions of the ribs 
which are most inaccessible for the radiographer, namely, between the 
anterior and posterior axillary lines. Side views would frequently be 
necessary, but satisfactory lateral radiographs of the chest are usually 
difficult to obtain. Fractures frequently occur in the localities where 
the shadows of the ribs are more or less obscured by the liver and heart, 
and in stout subjects the examination of the ribs in these areas is by no 
means easy. When the diagnosis is practically cer.tain clinically, an 
x-ray examination is not necessary, as a rule. When an ^r-ray examina- 
tion is absolutely necessary, however, it can usually be successfully and 
satisfactorily made, even in the presence of the most serious obstacles. 
The first two or three and the last two ribs can be easily shown throughout 
their entire extent. It might be said that the x-yslj examination is 
easiest in those localities in which the clinical examination is most diffi- 
cult, and vice versa. The x-yslj examination is especially valuable for 
the detection of incomplete and fissured fractures. 

Vertical displacement is easily shown, but this is not the case when 
the fragments are driven in. Separations at the costochondral junctions 
cannot be demonstrated radiographically. 

The interpretation of old united fractures should receive careful 
consideration, especially in medicolegal cases. Various prominences 
and irregularities in outline are to be found in many ribs, and are easily 
mistaken for old fractures surrounded by callus. 

Osteoperiostitis. — The skiagraph is often of value in determining the 
presence of disease in the ribs, its exact location, and the extent to which 
the bone is involved. The same difficulties are to be encountered as in 
the examination for fractures. In caries, neither the presence of the 
condition nor the extent of bony destruction is likely to be shown unless 
the process has reached a comparatively advanced stage. A gummatous 
osteitis can usually be observed at a comparatively early stage unless 
the locality is inaccessible to the x-rsij examination. When sinuses exist, 
they should be injected with bismuth or iodoform before the examina- 
tion is m^de, 



INJURIES OF THE THORAX AND THORACIC VISCERA 57 

Tumors. — Tumors associated with appreciable loss of bony substance 
may usually be demonstrated if the region is accessible, and the examina- 
tion in such instances may be of considerable value. Exostoses are 
easily shown. Sometimes a small exostosis, by pressure upon an inter- 
costal nerve, may be the cause of intercostal neuralgia, and under such 
circumstances an a;-ray examination might be the only way in which 
the cause of the trouble could be discovered. 

Deformities. — Deformities of the ribs may also produce symptoms 
of nerve pressure, and the skiagraph is the most satisfactory means of 
revealing the cause. The particular deformities to be noted are those 
resulting from fractures, either in the form of permanent displacement 
or excessive callus; close approximation of the bones such as is seen in 
marked scoliosis; or those due to rickets. 

The Sternum. — The sternum is one of the most difficult bones of the 
body to radiograph, and, until recently, very few satisfactory pictures of 
it have been made. The manubrium is the easiest portion to examine, 
but considerable ingenuity is required to obtain skiagraphs of even this 
small portion. The x-rsij examination for fractures or dislocations at 
the junction of the manubrium and gladiolus is unsatisfactory, but 
fortunately the diagnosis is easily determined clinically. 

Disease and tumors are likewise difficult to demonstrate for the same 
reasons, and an a;-ray examination is of practically no value unless the 
extreme upper portion of the bone is involved. 

The Dorsal Vertebrae.— As a rule, this is the most difficult portion 
of the spine to radiograph satisfactorily, mainly because clear details of 
the vertebrae are obscured by the superimposed shadows of the great 
vessels, heart, liver, and sternum. In thin subjects, clear details are 
easily obtained, but the stouter the individual the more unsatisfactory 
the skiagraph. 

Fractures. — Fractures of the dorsal vertebrae can, of course, be easily 
demonstrated under favorable circumstances. The difficulties attend- 
ing the o^-ray examination of this portion of the spine in a case of recent 
fracture are to be added to those just mentioned. Lateral views when 
they are obtainable show the bodies to the best advantage, especially in 
dislocations, but the upper dorsal vertebrae can seldom be skiagraphed in 
this direction, and it is useless to attempt a lateral radiograph in stout 
subjects. 

Caries. — Caries of the bodies of the dorsal vertebrae is difficult or 
impossible to demonstrate unless the destruction has advanced far 
enough for the disease to be clinically evident beyond question. Occa- 
sionally, in very thin subjects. Pott's disease has been recognized at a 
very early stage by the skiagraph. In young children the examination 
is always unsatisfactory because of the incomplete ossification of the 
vertebral bodies. 

Tumors. — The rr-ray examination for tumors of this portion of the spine 
is of little practical value. In rare instances, however, the skiagraph 
may give some valuable information. 

To credit the radiograph with any practical diagnostic value in con- 
nection with tumors of the spinal cord is, of course, absurd. 



58 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

Scoliosis. — Scoliosis is easily demonstrated, and the extent of the 
deformity, the degree of rotation of the vertebral bodies, and many of 
the secondary deformities, such as those of the ribs, can be readily 
shown. Details are not so essential in this condition, but, as a rule, 
they are unusually clear because the curve of the spine carries the 
vertebrae away from some of the structures which normally obscure 
them. 

Arthritis. — ^Arthritic conditions involving the spine, such as the type 
associated with chronic osteo-arthritis, for example, cannot be demon- 
strated unless there is some marked structural change. Bony and carti- 
laginous absorption are to be noted in advanced stages of the atrophic 
types, and excessive bony deposits in the hypertrophic type. 

Foreign Bodies. — ^The examination for foreign bodies in the thorax, 
other than those associated with gunshot injuries, requires special men- 
tion because of the localities in which they lodge and the avenues of their 
introduction, both of which are peculiar to this portion of the body. 

Esophagus. — ^The majority of the cases examined for suspected 
bodies lodged in the esophagus are young children. Many of the 
articles which are swallowed and which are too large to pass through are 
first halted at the uppermost constriction where the pharynx and esopha- 
gus join. Here they may be easily palpable through the mouth, and, if 
so, can be removed without the assistance of localization by the radio- 
graph. The level at which the radiographer usually finds bodies lodged 
is about that of the suprasternal notch. This point is slightly below the 
first constriction and slightly above the next lower one, where the left 
bronchus crosses the esophagus. The point of lodgement, however, 
depends somewhat upon the nature and size of the object swallowed. 
Straight pins and small open safety pins passing point downward may 
lodge anywhere, although the former invariably pass, and even the latter 
usually do. Long straight pins are much more apt to lodge than short 
ones if they pass point downward. Large open safety pins will usually 
lodge high up in children if they pass the first constriction. 

In children, the majority of the objects found lodged at the point just 
mentioned are coins — more often pennies, but sometimes nickels. Dimes 
will usually pass, and larger coins will not enter the esophagus of children, 
although a half-dollar has been found lodged at this level in the esophagus 
of an adult. Other articles commonly swallowed by children, and likely 
to lodge, are buttons, jackstones, and rounded flat metal whistles. In 
rare instances, tooth plates have been swallowed by adults and have 
lodged in the esophagus. 

An x-ray examination is practically imperative in all cases in which the 
lodgement of a foreign body in the esophagus is suspected. Primarily 
it is necessary in order to determine with absolute certainty whether 
a body has lodged or not. In addition, it will show the nature of the 
object and its exact location, so that the suxgeon is at once able to decide 
upon the most appropriate method for extraction. 

The examination for less dense objects, such as pieces of chicken bone 
or nut shells, is usually somewhat different from that in case of the much 



INJURIES OF THE THORAX AND THORACIC VISCERA 59 

denser ones^ and is far more difficult. The radiographer should, there- 
fore, have some previous knowledge of the nature of the object for which 
he is to examine. Fish bones are extremely difficult and usually impos- 
sible to demonstrate in the skiagraph, but they usually pass, and the 
sensation referable to their lodgement is generally due to the trauma 
produced by their passage. 

The Air Passages. — Many objects which may gain entrance into and 
become lodged in either the larynx, trachea, or bronchi cannot be detected 
by means of the a:-rays, because of their lack of sufficient density to cast 
shadows. Some objects, of comparatively slight density, if lodged in 
the larynx or upper portion of the trachea, may be more or less plainly 
shown in a lateral view of the neck when a radiograph made in the 
anteroposterior direction would give no indication of their presence. 

Gunshot Injuries. — Primarily the essential object of the examination is 
to determine the presence of the missile; this the skiagraph does invari- 
ably. It will also show the exact location of the missile and thereby 
aid in determining its accessibility for removal. Methods of accurate 
localization by means of special instruments of precision may be em- 
ployed advantageously in some instances, but, as a rule, fore-and-aft and 
lateral views will suffice. 

Aneurysms. — Radiographs have frequently shown aneurysms when 
their presence could not be detected clinically, but in many such instances 
the pictures have been misinterpreted and the a:-ray diagnosis has been 
incorrect. Moreover, the skiagraph has not infrequently failed to reveal 
the presence of an aneurysm that undoubtedly existed. But ordinarily 
the x-YSiy diagnosis is not especially difficult in the hands of a careful 
examiner with a reasonable amount of experience, although there are 
instances in which it is extremely difficult. 

There is, perhaps, no other condition better adapted to examination by 
the fluoroscope. It is a most convenient method for both diagnosis and 
study of thoracic aneurysms, and reveals some features that cannot be 
shown readily by the skiagraph. Its superiority over the latter for 
diagnosis alone, however, is questionable, and any special advantages 
it may possess certainly do not justify the risks entailed in its routine use, 
since there is no way of employing the fluoroscope with absolute safety. 
Improvements in apparatus have made it possible to radiograph the chest 
of the average individual in a fraction of a second, and satisfactory 
stereoscopic radiographic examinations of the thorax are within the 
range of possibility. When this state of perfection has been realized, 
the accuracy of the x-rsij diagnosis of aneurysms will be markedly in- 
creased, and the fluoroscope will practically cease to hold any special 
advantage beyond the observation of pulsation. 

Aneurysms of the aortic arch are peculiarly adapted to examination 
by means of the ^r-rays because of the transparent structure of the sur- 
rounding lung tissue. The heart and aortic arch are readily observed 
unless other abnormal shadows obscure them. The outlines of the 
normal aorta are nearly or entirely overshadowed by the spine and 
sternum, but this is unimportant for the reason that any enlargement or 



60 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

displacement of the vessel is always perceptible unless obscured by 
abnormal structures. 

As to the interpretation of a radiograph taken for aneurysm, if there 
is no marked enlargement of the aortic shadow, aneurysm may be 
excluded. If, however, it is apparently abnormally enlarged, the next 
question to decide is as to whether this shadow arises from the aorta or 
is due to some other condition that may be present. This is often a 
difficult point to determine with certainty. If the abnormal shadow can 
be positively identified as that of the aorta, it is often necessary to deter- 
mine next whether the condition is an aneurysm or a dilated aorta. This 
too is sometimes a difficult problem, and, as a rule, the correct solution 
requires judgment and experience. 

Radiographically, aneurysms of this locality may be classed primarily 
as diffuse and those which are more or less localized, or sacculated. 

Diffuse aneurysms involve the entire arch, or a greater part of it. 
When small, they may be mistaken for a condition known as dilated 
aorta. 

Localized, or sacculated, aneurysms can be easily detected, as a rule, 
in any of the three portions of the arch. A small one involving the trans- 
verse portion and extending directly upward may escape detection, 
especially in stout subjects, because it is more or less obscured by the 
shadow of the spine. A dilated or hypertrophied left heart may be 
confusing in connection with a suspected aneurysm of the descending 
portion of the arch. 

Aneurysms involving the descending portion of the thoracic aorta, or 
the part of the vessel below the arch, are much more difficult to demon- 
strate because of the overlying cardiac shadow. They are comparatively 
uncommon, however. They usually involve that portion of the vessel 
just above the point where it passes through the diaphragm. 

Differential Diagnosis. — Radiographically, aneurysmal shadows are to 
be differentiated from those of the following conditions. 

1. Mediastinal Tumors. — ^This diagnosis is not difficult, provided the 
shadow of the aorta can be determined in case of tumor or the enlarged 
shadow can be positively identified as that of the vessel in case of aneu- 
rysm. If the identity is questionable in case of a single large shadow of 
considerable density and of uniform outline, the diagnosis is difficult. 

2. Enlarged Mediastinal and Bronchial Lymph Glands. — An experi- 
enced examiner is not apt to confuse the shadows of such structures with 
the appearance of aneurysm if the skiagraphic details are satisfactorily 
clear. 

3. Localized Empyema or Thickened Pleura. — ^The skiagraphic appear- 
ance may occasionally bear some resemblance to that of aneurysm. 
Under such circumstances the clinical history of the case is essential in 
making a correct diagnosis. 

Localized Thickened Pleura. — ^The same remarks are applicable in 
connection with this condition. 

5. Tortuosity or Displacement. — Familiarity with the normal varia- 
tions in placement, size, and contour are essential to the correct inter- 
pretation of abnormal appearances. 



INJURIES OF THE THORAX AND THORACIC VISCERA 61 

6. Dilated Aorta. — Under certain circumstances the distinction from 
anemysm may be impossible because of the presence of other diffuse 
shadows having a density equal to or greater than that of the vessel. 

Liquid effusions of any kind filling one or both pleural cavities or the 
pericardium render the radiographic diagnosis of aneurysm difficult or 
impossible. Our knowledge concerning the diagnostic value of the 
a:-rays in regard to aortic aneurysm may be summarized as follows : 

The appearance of normal shadows in the region of the thoracic aorta 
in a skiagraph in which the details are satisfactorily clear is the most 
reliable evidence against aneurysm. Its presence or absence can be 
demonstrated with accuracy in the large majority of instances. Most 
errors arise from inexperience, poor negatives, faulty technique, or 
failure of the clinician to cooperate with the radiographer in the inter- 
pretation of the skiagraph, especially in doubtful cases. An a;-ray diag- 
nosis may be impossible in rare instances. A skiagraphic diagnosis can 
often be made at a very early stage of the disease and sometimes even 
earlier than any definite clinical signs can be detected. ^Mien aneu- 
rysm is suspected, but the clinical diagnosis is uncertain, the x-tsly 
examination is, in the majority of instances, the most valuable and 
accurate means for determining its presence or absence. Even when 
the clinical evidence seems apparently unquestionable, the skiagraph not 
only gives confirmatory evidence, but it will, in addition, accurately 
demonstrate the size and position of the aneurysm, and is always a 
safeguard against a possible error. 

Innominate and subclavian aneurysms are as well adapted to a:-ray 
examination as are those of the aorta, although their detection is usually 
more difficult. For this reason, and because of their comparative 
in frequency, they are likely to be overlooked when their presence is 
unsuspected. A skiagraphic examination before an operation upon an 
aneurysm of one of these vessels is of importance for determining its 
size, character, and extent, and the possibility of associated involve- 
ment of the aorta by an aneurysmal dilatation independent of or 
continuous with that of the smaller vessel. 

The Lungs and Pleura.— The surgical affections of these structiu-es, 
in which the a;-ray examination is applicable for purposes of diagnosis, 
are abscess and gangrene of the lungs and pleural effusions and empyema. 

Exposure of the chest to a;-rays during the acute stage of pneumonia 
is not advisable unless it seems absolutely necessary from the point of 
view of immediate surgical intervention. 

Abscess of the Lung. — ^The distinction between abscess and localized 
empyema is one that is often required, and one that is sometimes difficult 
to make clinically. The radiograph is a reliable means of differentiating 
between these two conditions. 

With reasonable care and experience the skiagraphic appearances of 
abscess and cavity should not be confused. A knowledge of the clinical 
history of the case is always necessary as a safeguard against errors in 
the interpretation of the pictures. 

Gangrene. — If this condition is suggested clinically the skiagraph may 
be a valuable aid in the diagnosis. It is unquestionably of value in the 



62 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

localization of the affected area. Here especially a knowledge of the 
clinical data is essential. 

Pleural EfEusions and Empyema. — ^The presence of fluid in the pleural 
cavity, whether serum, blood, or pus, can be accurately and easily demon- 
strated by the skiagraph. The o^-ray diagnosis is especially valuable 
in connection with localized effusions and empyemas. The skiagraph 
is likely to be inadequate or misleading unless careful attention is paid 
to certain important points, such as the position of the patient, the 
position of the plate and tube, etc. The skiagraphic appearance of 
an area of greatly thickened pleura may closely resemble that of a 
localized effusion or empyema, and vice versa, and this fact, therefore, 
should not be overlooked. 

Subphrenic Abscess. — ^This condition may be appropriately mentioned 
here because of the question of differential diagnosis from certain intra- 
thoracic conditions, especially empyema. Under certain circumstances, 
and with the exercise of care and ingenuity, a subphrenic abscess may 
be diagnosticated by means of the x-raj examination. 

SURGICAL AFFECTIONS OF THE ABDOMEN AND PELVIS. 

Considering the number and the variety of pathological conditions 
associated with the abdominal organs, the field for x-yslj diagnosis is a 
comparatively limited one. Perhaps this method of examination is 
most helpful in the diagnosis of certain conditions of the urinary and 
the gastro-intestinal tract. 

Urinary Tract. — Renal Calculus. — The radiographic examination is 
the most valuable and the most uniformly accurate method at our com- 
mand. It must not, however, be regarded as infallible. 

No skiagraphic examination for renal calculus can be entirely satis- 
factory unless the patient has received an adequate preliminary prepara- 
tion. This implies that the stomach should contain little or no food, 
that the intestinal tract should be nearly empty, particularly in regard 
to gas, and that no pills or tablets should have been taken after a time 
which would allow any chance of one remaining in the intestinal tract 
when the examination is made. Salol in particular casts a distinct 
shadow. 

Given a well-prepared patient, an efficient apparatus, and a skilful 
operator and interpreter, the most but not all of the sources of failure 
or error are eliminated. 

The presence of excessive amounts of fat in the abdominal walls and 
omentum, thick abdominal muscles, tumors, a pregnant uterus, or 
ascites may obscure the shadow of a stone. 

A skiagraph of the kidney area, to be considered reliable for diagnosis, 
should show the shadows of the psoas muscles at least, and, to be still 
more certain of accuracy, it should have sufficient detail to show the 
shadows of the kidneys in addition. An absolute diagnosis, whether it 
be positive or negative, should not be made from a single skiagraph 
or even one examination. 



SURGICAL AFFECTIONS OF THE ABDOMEN AND PELVIS 63 

Shadows similar to those of calcuh may be cast by calcified lymph 
glands, circumscribed collections of pus in the kidney, small enteroliths, 
and fecal or other concretions in the lumen of the appendix. The pos- 
sibility of error from such sources is influenced to some extent by the 
skill and experience of the examiner, though it cannot be altogether 
eliminated. 

In the skiagraphs of pelves of many normal individuals will be found 
shadows which have an appearance practically identical with that of 
ureteral calculi. The position of such shadows often distinguishes 
them from those of calculi. This is not always the case, and in some 
instances the only way of proving the exact identity of the shadows is to 
radiograph the patient with a catheter and stilette in the ureter, or to 
make a stereoscopic examination, but the former method is preferable. 

Most of the extraureteral shadows are due to the presence of phle- 
boliths in the pelvic veins or to small sesamoids in the tendons attached 
to the ischiatic spine. A less frequent source of error is the presence of 
calcified pelvic lymph glands. Should one of these be located about 
the line of the ureter, it is practically impossible to distinguish it radio- 
graphically from a ureteral calculus except by skiagraphing after cathe- 
terization. A calculus lodged in the portion of the ureter overlying the 
bony pelvis, an infrequent position, may be obscured by the shadow^ of 
the bone. 

Nephroptosis. — ^The displaced kidney is more readily shown than the 
normally placed organ. The preliminary preparation is that indicated 
in the examination for calculus. 

Tumors. — Under favorable conditions the skiagraph will in many 
instances render valuable assistance in the diagnosis of renal tumors, 
especially in regard to the identification of those in which the renal origin 
is uncertain. 

Pyonephrosis. — In many instances the skiagraph will aid materially 
in the diagnosis of circumscribed abscess in the kidney substance. The 
shadow of such a lesion has sometimes been mistaken for stone. 

Hydronephrosis. — The shadow of the enlarged kidney and sometimes 
a faint shadow of a dilated pelvis are the skiagraphic data obtainable 
in this condition under favorable circumstances. 

Perinephric Abscess. — ^The skiagraph is only of negative value in 
diagnosis. 

Vesical Calculus. — ^The x-rsij diagnosis of vesical calculus is more 
difficult and more uncertain than that of renal calculus. This is mainly 
because of the position and anatomical relations of the bladder and the 
stone and the consistency of the majority of vesical calculi. Conserva- 
tively speaking, we may regard the skiagraphic examination as a very 
valuable and fairly accurate means of diagnosis in vesical calculus, 
but having a higher percentage of error than in connection with renal 
calculus. The preliminary preparation is that called for in renal exami- 
nations. 

Prostatic Calculi. — ^The presence of calculi may be read^^^y detected, 
but distinction from vesical calculi is more difficult. 



64 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

^ Foreign Bodies. — ^The presence of foreign bodies in the bladder, intro- 
duced accidentally or partially by intent, is easily determined by the 
skiagraph. 

Liver and Gall Bladder. — In thin or moderately thin subjects the 
general outline of the liver is easily obtained in the skiagraph. The 
radiograph is especially accurate in demonstrating the position of the 
organ, especially its lower right border. This is important in connection 
with the examination of cases of gastroptosis. The size of the liver can 
be estimated from the skiagraph, though the shadow is often misleading. 

In thin subjects abscesses and cysts of the liver may sometimes be 
detected. Sinuses may be outlined by previous bismuth injections. 

Biliary Calculus. — As yet, the a:-ray examination in connection with 
biliary calculus has proved so unsatisfactory and so unreliable as to 
render it of no practical value in the diagnosis of this condition. In 
comparatively rare instances and under especially favorable conditions 
a positive diagnosis has been made, and confirmed later, but a negative 
x-rsij diagnosis has so far been absolutely valueless. Notwithstanding 
the unsatisfactory results in the past, it is more than likely that the rapid 
strides now being made in the improvement of apparatus and methods 
will tend to make the x-ray diagnosis of gallstones sufficiently reliable 
in the near future to be dependable, but only under certain favorable 
conditions. It will be necessary, however, to limit the use of the skia- 
graphic examination strictly to those cases in which the latter term is 
applicable. "Favorable conditions" would imply comparatively thin 
subjects; the location of stones in the bile ducts, especially the common 
duct, and, if in the gall-bladder, the absence of distention with bile; and 
the absence of conditions which would tend to interfere with the impor- 
tant details essential to the success of such an examination. Careful 
and thorough preliminary preparation of the patient is of course impera- 
tive. The size of the stones would influence the likelihood of their deteq- 
tion, and the presence of lime salts would render it more certain. 

The Pancreas. — ^The attempt to employ the skiagraph in connection 
with the examination of the pancreas has with very rare exceptions met 
with no success. The x-tslj examination is, therefore, of no practical 
value in the diagnosis of pancreatic affections except possibly calculus. 

The Spleen. — ^Tbe spleen is easily skiagraphed, provided the patient 
is not too stout, but there is seldom any ^practical use for the a^-ray 
examination of this organ beyond the determination of its position. 

Abdominal Aneurysms. — Aneurysms of the abdominal aorta are 
difficult to demonstrate satisfactorily by means of the skiagraph except 
in thin subjects. It is possible that in some of the cases in which this 
portion of the vessel is the supposed seat of the lesion the aneurysm is 
really in the lower extremity of the descending thoracic aorta. 

Foreign Bodies. — Foreign bodies in the abdomen and pelvis can 
usually be localized within reasonably accurate limits. Absolute localiza- 
tion is difficult because the movements of the abdominal walls and the 
constant variations in the dimensions of the abdomen are serious ob- 
stacles to the use of special localization apparatus. 



THE GASTRO-INTESTINAL TRACT 65 

Tumors. — Intra-abdominal tumors in the early stage of their growth 
cannot be detected by radiographic examination; later the shadows may 
show the extent and location of tumors and demonstrate the structures 
from which they spring or with which they are connected. 

The Lumbar Spine. — ^This portion of the spine is easily and satis- 
factorily radiographed unless the subject is very stout. Often such 
comparatively slight injuries as fractures of the transverse processes can 
be recognized in no other way. Marked changes can be seen in cases of 
advanced spinal caries, but rarely any in the beginning. Sinuses may 
be followed after preliminary injection with bismuth or iodoform sus- 
pension. The changes of lateral curvature, typhoid spine, and spondy- 
litis deformans are clearly shown. The radiographic examination of 
spina bifida is unsatisfactory in its results and is of little or no practical 
value. 

THE GASTRO-INTESTINAL TRACT. 

In the application of the a;-rays in the diagnosis of abdominal and pelvic 
conditions, the examination of the stomach and large bowel may now be 
regarded as next in importance to that for renal calculus. These hollow 
viscera are rendered distinguishable only by the shadows of some opaque 
substance within them, usually the subnitrate of bismuth — introduced 
by mouth in the examination of the esophagus and stomach, and either 
by mouth or rectum in the case of the large intestine. All radiographs 
must be anatomically accurate, and must be so interpreted as to convey 
the correct impression of the existing conditions and relations which 
they are intended to represent. 

Esophagus. — In the examination of this portion of the tract, accurate 
data can be obtained in regard to the presence, location, and extent of 
strictures, dilatations, and congenital and acquired diverticula. In some 
instances in which comparatively extensive growths are the causes of 
stenoses the skiagraph is capable of furnishing many important and 
reliable facts concerning the condition. 

Stomach. — Perhaps the widest application of this method is in the 
examination of the stomach. The important data directly or indirectly 
obtainable are: (1) The exact outlines, position, and size of the stomach 
under varying conditions; (2) a definite knowledge of the factors directly 
or indirectly concerned in the production of ptosis and dilatation, such 
as the position of the pylorus, the actual existence or the likelihood of a 
duodenal kink, the length of the gastrohepatic ligament, the degree of 
tonicity or relaxation of the muscular coat, the existence of ptosis 
of the liver, the possibility of traction by a ptosed colon, and in some 
instances the presence of causes of pyloric obstruction other than kinks; 

(3) an approximate knowledge concerning the motility of the organ; 

(4) valuable suggestions in regard to the most appropriate method of 
treatment of the gastroptosis and dilatation; (5) definite knowledge of 
the actual mechanical and anatomical results derived from any methods 
of treatment employed. 

5 



66 THE APPLICATION OF X-RAYS IN SURGICAL DIAGNOSIS 

The presence of "hour-glass" constrictions is readily determined. 

The skiagraph is capable not only of demonstrating the above-men- 
tioned facts with dependable accuracy, but also with more certainty and 
uniformity, as a rule, than any other methods at our command, and in 
many instances the information derived from the x-tslj examination is 
practically unobtainable by any other means. 

Until recently the a::-rays promised little in the early diagnosis of car- 
cinoma, but quite recent advances in stomach examination have made 
it possible to obtain fairly reliable data that will frequently verify or 
strengthen an uncertain chnical diagnosis at an early stage of the disease. 

Small Intestine. — ^The examination of this portion of the tract has 
so far been unsatisfactory. Its successful application has been practically 
limited to the detection and location of various forms of obstruction, in 
which relation the skiagraphic information has occasionally proved most 
useful. 

Colon. — Next in importance to the examination of the stomach by 
this method is the examination of the colon. It is undoubtedly the most 
reliable and accurate means we have of determining displacements of 
this portion of the gut. The presence and the location of obstructions 
are readily shown. In connection with obstruction due to newgrowths, 
it is often possible to determine whether the latter involves the walls of the 
colon or encroaches upon the lumen by pressure from without. In some 
instances the presence of adhesions between loops of displaced large 
bowel may be suggested. In cases of fecal fistula, it is possible, after 
injection of bismuth through the external opening, to determine by the 
skiagraph the portion of the bowel into which the fistula opens. 

Sigmoid. — ^This portion of the bowel is also easily examined by 
this method. Its important application is in the diagnosis of ptosis, 
redundancy, and obstructions. 



INJURIES AND SURGICAL AFFECTIONS OF THE SOFT PARTS. 

The field of application for the x-rsij examination in connection with 
injuries and other surgical affections of the soft parts is comparatively 
limited. The few instances in which it is applicable will be given brief 
mention. 

Arteriosclerosis. — The presence of advanced sclerosis in any of the main 
vessels of the extremities and of their larger branches is easily determined 
by means of the skiagraph. Although its employment for this purpose 
is seldom necessary, it may occasionally be of some practical value. 

Traumatic Aneurysms. — ^The skiagraph is sometimes useful in connec- 
tion with this condition, especially in popliteal aneurysms. 

Bursitis. — In certain localities the skiagraph serves a very useful 
purpose in the diagnosis of this condition, especially in connection with 
the deltoid bursa. 

Myositis. — ^The skiagraph is especially useful as a means of differential 
diagnosis in this condition. Myositis ossificans is the particular type 



INJURIES AND SURGICAL AFFECTIONS OF THE SOFT PARTS 67 

in which it is directly appHcable for the examination of the condition 
itself. 

Rupture of Muscles. — ^The skiagraph is sometimes useful in the diagnosis 
of this injury. 

Painful Stumps. — ^The a:-ray examination of painful stumps is often 
the only satisfactory means of determining the cause of this sequel 
of amputations. 



CHAPTER III. 

INFLAMMATION. 

Inflammation, the tissue reaction against injury, has for its end the 
removal of necrotic material, the neutralization of toxins, and the restora- 
tion of structural continuity. 

Following trauma without infection, the local symptoms are slight and 
transitory, nor are there constitutional symptoms other than those inci- 
dent to the shock of injury and the fever of reaction and absorption. 
By the third day these symptoms should have disappeared or be obvi- 
ously subsiding. 

Following infection, the local and constitutional symptoms become 
progressively more marked, and are well pronounced by the third to the 
fifth day, thereafter running a course dependent on freedom of drainage, 
virulence of infection, and tissue resistance. 

The local symptoms of inflammation are heat, redness, swelling, pain, 
tenderness, and alteration of function. 

Heat and redness can be detected only in inflammations of the surface 
or those lying near it. Swelling can be noted in parts which are normally 
palpable through the parietes. The surface edema of deep infection is 
a valuable localizing sign. Tenderness and pain, usually associated with 
protective muscular rigidity, are often the symptoms which indicate the 
seat of a deep-seated inflammation. 

The constitutional symptom of inflammation is fever, usually accom- 
panied by leukocytosis of the polymorphonuclear type. 

High fever, rapid pulse, and a pronounced leukocytosis are indicative 
of an organism stimulated to powerful reaction against an active 
infection. Moderate fever, slight leukocytosis, and running pulse 
suggest an organism overwhelmed by the infection. 

In accordance with the infecting agent, its virulence and the tissue 
resistance inflammation may be circumscribed or diffuse, acute or chronic. 
The same form of bacterial infection may cause a slight and transitory 
inflammation, suppuration, or gangrene. Acute suppuration is usually 
due to the ordinary pyogenic organisms. The formation of cold abscesses 
is particularly characteristic of the tuberculous and the post-typhoidal 
infections. It may, however, follow an attenuated or highly resisted 
infection by the ordinary pyogenic microorganisms. 

Fever. — Fever associated with increase in pulse and respiratory rate, 
headache, loss of appetite, lessened peristalsis, deficient secretion and 
excretion, and general muscular pain, occurs at least in a slight degree 
after all severe traumata. It is an almost invariable symptom of the acute 
infections, unless they be of overwhelming and shocking intensity. It 



INFLAMMATION 



69 



is usual in chronic infections, and is frequently observed in rapidly 
growing neoplasms. 

Traumatic Aseptic Fever. — In its lightest form it is observed after 
fractures or clean wounds. The temperature rises in the first twenty- 
four hours to between 99° and 101"^. Neither the pulse nor the tempera- 
ture is materially affected, nor are other symptoms of malaise pro- 

FiG. 18 




Carcinoma of stomach. Partial gastrectomy and gastro-enterostomy. The chart shows the 
effect of shock following the operation, the temperature dropping to 9G° and the pulse rising 
to 120°. 

Fig. 19 



I 


-1 


CL 




TEMPERATURE l,FAHR.) 

97 98 99 100 


2/27 


116 


26 


M 












80 


24 


E 






' 


--_- 




28 


82 


22 


M 








r — 




80 


24 


E 




f 
' 








3/1 


82 


22 


M 












80 


22 


E 










2 


74 


20 


M 






^^ 


-"^ 




84 


24 


E 






^ 






3 


72 


20 


M 












84 


20 


E 






"^Ma 






4 


84 


20 


M 






y^ 






96 


22 


E 






N. 






5 


84 


24 


M 






k--^ 






96 


24 


E 


! — ""'"~'' — ^ — 







Appendectomy. Typical traumatic reactionary fever. 



nounced. Within the next forty-eight hours the fever drops to about 
normal unless there be a large thrombus, in which case it may remain 
of the same grade for three or four days. There may be slight leuko- 
cytosis, and albumin and a few red cells may be found in the urine. 
When a wound, either operative or otherwise, has been attended by pro- 
found shock the temperature rise is correspondingly greater. 

This form of fever, due to the absorption of devitalized tissues and 



70 



INFLAMMATION 



effused blood, at times partially to reaction from the shock, is charac- 
terized by its transitory nature, its tendency toward subsidence rather 
than increment after the first onset, and the absence of associated toxic 
symptoms. At the seat of traumatism there is swelling, with heat, ten- 
derness, and redness, reaching its moderate maximum about the third 
day and thereafter rapidly subsiding. 

Fig. 20 



UJ 

< 


1 


d: 




TEMPERATURE (fAHR.) 

9n 98 99 100 


12/19 


64 


22 


M 


1 






86 


22 


E 




i 






20 


84 


22 


M 








/" 




90 


26 


E 








^ 




21 


80 


24 


M 








^ 




80 


22 


E 






\ 






22 


74 


20 


M 






.^ 


' 




72 


20 


E 






\, 






23 


Ti 


20 


M 




m^ 


^ 






78 


20 


E 






^^-^3 






24 


74 


20 


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<^ 






78 


18 


E 






s. 






25 


74 


20 


M 






y^ 






76 


22 


E 













Cholelithiasis. Typical moderate traumatic reaction. 



Fig. 21 



UJ 

2 


^ 
2 


i 




TEMPERATURE (fAHR.) 

97 98 99 100 101 


2/9 






M 














102 


26 


E 














10 


78 


22 


M 















90 


22 


E 








-» 


^^^, 




11 


94 


20 


M 











^-^ 




84 


22 


E 










Ni 




12 


96 


22 


M 








^-^^^ 






82 


22 


E 








^^ 






13 


84 


22 


M 








^ 






86 


22 


E 














14 


96 


20 


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"^ 






90 


22 


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-.^^^^^ 






15 


96 


20 


M 








L-^^^* 






90 


20 


E 






*< 








16 


78 


20 


M 
















E 















Incarcerated femoral hernia. Fever continued several days without any visible evidence of 
infection. There was, however, after the first day a gradual fall. There was no pulse hurry. 



Septicemia. — Following an infected wound, there may develop within 
the first twenty-four hours the fever characteristic of reaction. Instead 
of subsiding on the second or third day, this fever becomes more pro- 
nounced, exhibiting a morning remission and an evening rise. It is 
associated with headache, general muscular pain, distaste for food, 



INFLAMMATION 



71 



constipation, and high-colored, scanty urine and pronounced leukocytosis. 
If the wound has been properly drained, the vital resistance high, and the 
infecting organism one of ordinary virulence, this fever reaches its maxi- 
mum on the third or the fifth day and then gradually subsides. Under 
other circumstances, pus under tension, virulent infection, or low resist- 



FiG. 22 



us 

< 


D 


a: 




97 98 


TEMPERATURE (fAHR.) 

99 inO 101 102 103 


i/s 


90 


24 


M 


















90 


22 


E 




I 














9 


92 


22 


M 




V 














108 


28 


E 








' ' — ■ 










10 


114 


28 


M 










■_ 




— ' t 


106 


28 


E 
















11 


106 


28 


M 










— ■ 








100 


28 


E 








©=: 




' =1® 






12 


96 


26 


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EL— ' 


r-^" 






96 


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^ 






13 


94 


24 


M 








« — 


---^ 








84 


22 


E 








1 










U 


80 


22 


M 








_. 


1 






83 


22 


E 




N. ' 


i 







Retention cyst of breast, followed after excision by sloughing of a portion of the overlying 
skin. Sudden rise in temperature and gradual daily fall. 



Fig. 23 



§ 


-I 

3 


a 




(17 98 


99 


TEMPERATURE (FAHR.) 

100 101 102 103 104 


3/i 


82 


20 


M 


1 




1 








94 


20 


E 






' — >>^__ 












5 


76 


20 


M 






__— — -1 ' 












88 


24 


E 






^ -— 


, 










(5 


86 


20 


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— - 












112 


28 


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7 


108 


24 


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■ 


'~* 


104 


24 


E 












^^^^ 








8 


102 


22 


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-1 


■ ■ 








96 


22 


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® ■ 




^-^ 








9 


96 


20 


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. — - — ® 








90 


20 


E 










^-^ 










10 


88 


20 


M 








__^ 


— ^ 










106 


22 


E 








" — ■ 













Perforating gastric ulcer. Convalescence normal until fourteenth day; temperature then began 
to rise. The chart shows an unusual temperature jump due to a small parietal abscess. Pulse 
but slightly affected. Prompt subsidence of symptoms on drainage. 



ance, this fever continues, ranging from 101° to 105°, with nocturnal, 
often irregular exacerbations, the latter not infrequently accompanied 
by a chill, and being suggestive but not diagnostic of the development 
of other suppurating foci through the medium of septic emboli. 

If the systemic reaction against the infecting agent be well expressed, 
there will be a strong, regular pulse proportionate in rapidity to the 



72 



INFLAMMATION 



degree of fever and pronounced leukocytosis (polymorphonuclear). A 
pulse disproportionately rapid as compared with the temperature and 
slight leukocytosis are suggestive of reactive failure. 

A long continuance of acute septicemia is impossible. There is rapid 
emaciation, profound muscular degeneration indicated by the increasingly 



Fig. 24 





3 


q: 




TEMPERATURE (fAHR.) 

97 98 99 100 101 102 


2/22 


120 


24 


M 














106 


24 


E 
















23 


106 


24 


M 

















120 


26 


E 












^^^ 


>• 


24 


116 


24 


M 










«ft<-^ 


"■"^'^^ 




114 


26 


E • 










•^ 


..„^_^ 




25 


92 


28 


M 












- ^ 




94 


24 


E 
















20 


90 


25 


M 






i»^- — 










92 


26 


E 
















27 


88 


24 


M 










* 






98 


28 


E 
















28 


100 


24 


M 






.^-^ 










98 


24 


E 




' 


^ 











Perforated appendix. Immediate postoperative drop in temperature; rise in reaction plus 
continued sepsis; gradual drop from drainage and elimination. 

Fig. 25 



l- 
< 


i 


tc 




TEMPERATURE (fAHR.) 

97 98 99 100 101 102 103 


11/47 


102 


28 


M 








* 










106 


26 


E 














L ^^ 




28 


104 


28 


M 














- ** 




152 


48 


E 



















29 


134 


40 


M 














— ■ — ' 




118 


38 


E 


















30 


130 


36 


M 








^ 










126 


32 


E 








"^ 










12/1 


106 


32 


M 






^^,..— 


1 










110 


30 


E 






^ — - 


~« 










■ 
2 


106 


32 


M 






a.--— ^ 


L^^=* 










104 


32 


E 






*^^^----^ 


.^ 










S 


96 


30 


M 






^^^ 


-^^ 










112 


32 


E 






■ 


■ 




• 







Typhoid perforation. Immediate postoperative drop in temperature and rise in pulse rate. 



rapid and feeble heart action, pronounced anemia, and scanty and per- 
verted secretions and excretions. The dry, brown tongue, the feeble 
muttering, restless delirium, and the general condition of adynamia are 
characteristic. 

The local symptoms of increasing infection in the wound are more 
severe pain and tenderness, and on inspection the well-developed phe- 
nomena of acute inflammation. 



INFLAMMATION 73 

A mild form of septicemia may continue for months, characterized 
by evening rise of temperature, often night sweats and rigors, pulse 
hurry, and progressive emaciation. This is called hectic fever, the word 
hectic meaning habitual, and is seen typically in tuberculosis with mixed 
infection and inadequate drainage, as of the lungs. It is also character- 
istic of other chronic infections. 

Pyemia. — If septic thrombi are carried into the general circulation, 
metastatic abscesses will form, the lungs, spleen, kidneys, and joints 
being seats of predilection; the liver, if the infecting focus lie in the 
area drained by the portal vein. 

Paroxysms of chill, fever, and sweat are habitual in this condition 
and may recur several times in twenty-four hours; the temperature fluc- 
tuations are from 97° to 106°. The diagnosis is based on the local 
symptoms of infection in regions removed from the primary focus. 
Bronchopneumonia characterized by hurried, painful respiration cough, 
pleuritic pain, friction, percussion dulness, and the usual auscultatory 
sign is commonly the first manifestation. 

The particular variety of microorganisms which causes septicemia or 
pyemia is determined by cultures made from the blood. 

Fever of the acute or chronic septic type is common to both medical 
and surgical affections; before deciding that it is purely medical an 
adequate local cause should be searched for. If the fever be acute and 
violent, some surgical conditions which are at times overlooked should 
be considered. Among the more important of these are osteomyelitis, 
otitis media and its complications (especially in infants), infections of 
the accessory nasal cavities, and septic thrombosis of the kidney. Acute 
osteomyelitis and otitis media may have in children no early, readily 
elicited, localizing symptoms. 

Acute ulcerative endocarditis is in itself an adequate cause for violent 
sepsis, though it is very commonly a complicating factor. 

Even though a wound remains sterile, fever of such height may develop 
as to suggest the presence of a local infection. Two common causes of 
such fever are constipation and follicular tonsillitis. 

Constipation fever is characterized by a rapid rise during the course 
of an apparently smooth convalescence, with an associated coated tongue 
and heavy breath; usually there is a slight headache, with a history of no 
bowel movement for two or three days. The pulse as compared with 
the temperature is disproportionately slow (often characteristic of 
intestinal toxemia), nor is there more pain referred to the wound than 
has previously been experienced. The diagnosis is based on the 
prompt subsidence of these s}Txiptoms when the bowels are moved. 

The fever of follicular tonsillitis is t}^ical of acute infection, and would 
suggest a hyperactive bacterial growth in the wound were sore throat 
and the red, swollen, spotted tonsils not found. 

The malarial paroxysm may exactly simulate that of pyemia ; the com- 
plete and regular intermissions and the comparatively trifling effect 
on the general health are characteristic. The blood examination is 
diagnostic. 



74 



INFLAMMATION 



Complicating septic fevers there are a number of skin eruptions, 
herpetic, urticarial, scarlatiniform, or petechial, the latter of serious 
moment. 

In the absence of an obvious focus of entrance there may develop a 
condition of chronic sepsis characterized, not so much by fever, though 
this may be present in an irregular hectic form, as by deterioration of 
general health, multiform skin lesions, affections of the joints usually 
regarded as evidences of chronic rheumatism, loss of weight, slight 
albuminuria, and gastro-intestinal disturbances incident to absence or 
perversion of secretion or sluggish peristalsis. Blood examination may 
show the presence and the nature of the infecting organisms. When 
this fails, in the absence of organic lesions it is to be assumed that the 
symptoms are incident to a toxic absorption. 



Fig. 26 



I 








TEWPERATURE (fAHR.) 

97 9S 99 100 101 102 103 


'> 


80 


20 


M 


















106 


24 


E 




~ 


. 













7 


104 


22 


M 










/" 








106 


24 


E 










' - — ■ 


■— 


« 




8 


120 


26 


M 












1 






150 


28 


E 














-__ 


• 


9 


108 


26 


E 


© 


-==:^ 


-^ 












1© 


98 


22 


M 




^^^^^ 


.--->® 












92 


22 


E 




— - 


~--~— ~^- 












11 


90 


22 


M 






^^-^-^ 












86 


22 


E 






^^C^^^ 












12 


84 


24 


M 






^-"^ 












90 


22 


E 


i T^"-^-^ 













Vesical calculi. Perineal cystotomy. Immediate and violent sepsis. Characteristic rapid 
fall in temperature and pulse rate. 



To this form of hidden infection the term cryptogenic has been applied. 
This is not applicable unless the nose and its accessory sinuses, the 
teeth, mouth, throat, especially the tonsils, urethra, prostate, and seminal 
vesicles, and the anus and rectum have been carefully examined for signs 
of chronic infection. The coramon sources of such infection or toxemia 
which are not subject to direct examination are the appendix, gall 
bladder, the stomach and duodenum, and the renal pelvis. 

The fever symptomatic of a cholangitis, which frequently accompanies 
gallstones, is characterized by its irregular recurrences and its marked 
fluctuations, constituting, when depicted in graphic form, the so-called 
steeple chart. 

The septicemia which accompanies urethral traumatism is character- 
ized by its sudden onset and usually equally sudden subsidence. It is 
commonly expressed in the form of a single paroxysm which may occur 
in an hour from a trauma so slight as that incident to the gentle passage 
of a sound. There is chill, fever which may go as high as 106°, and 



INFLAMMATION 



75 



headache, often without corresponding rise in the pulse rate. It may 
subside completely in six to twenty-four hours, or may recur, assuming 
then the features of an acute septicemia. A rapid pulse is suggestive of 
a recurrence of such attacks. 

Erysipelas (Streptococcus). — Erysipelas, exhibiting a predilection 
for the face, is often initiated by chill, fever, and vomiting, and the 
formation of a red patch, with distinct, slightly raised borders, which 
rapidly invades the surrounding skin, is usually attended with moderate 
vesication and glandular enlargement, and is accompanied by the con- 
stitutional symptoms of an active sepsis. The inflammation is most 
intense at the borders and has a tendency to fade in the centre. 



Fig. 27 





i 


i 




TEMPERATURE (fAHR.) 

98 99 ion 101 102 103 104 


105 


4/11 


82 


20 


M 




















86 


24 


E 






— ■ — 














12 


100 


24 


M 




















122 


24 


E 




















13 


98 


24 


M 












— ■ — 








116 


24 


E 




















14 


94 


22 


M 

















— 




108 


24 


E 














"" * 






15 


96 


20 


M 












— — ■ 








114 


24 


E 












_______^ 








16 


90 


20 


M 












— ■ 








96 


20 


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17 


84 


20 


M 






____— 














90 


22 


E 






r^""^^-^ 













Urinary fistula and stricture. Internal urethrotomy; urinary sepsis developing eleven days after 
operation, following instrumentation but not immediately; duration longer than usual. 



A deeper infection, cellulitis, is characterized by more profound sepsis, 
a dusky rather than red color of the skin, pitting on pressure, ulti- 
mately bogginess from tissue destruction and pus formation, and the 
symptoms of at first a violent, then, if the infection be progressive, 
an overwhelming sepsis. This is the form of infection common in deep 
lacerated and contused wounds. 

Abscess, carbuncle, and erysipeloid are elsewhere described. 

Tuberculous Infection.— Tuberculous infection, against which none 
of the tissues of the body are immune, in its surgical form exhibits a 
predilection for the lymphatic glands, the vertebral bodies, and the 
growing epiphyses of the long bones. It is characterized by a chronic 
inflammation attended by few symptoms beyond swelling incident to 
organization of exudate and destruction of tissue. There is ultimately 
abscess formation, characterized by the appearance of a fluctuating 
tumor without other local symptoms until, by pressure necrosis and 
skin infection, the abscess is about to burst. 

The diagnosis of the tuberculous nature of the lesion is based upon its 
otherwise inexplicable occurrence, its chronic course, its age and loca- 



76 INFLAMMATION 

tion, incidence, the results of the tubercuHn test, and the examination 
of the discharge. Similar chronic inflammations may be caused by a 
great variety of infecting organisms, among them exceptionally the 
staphylococcus and streptococcus. 

Actinomycosis. — Actinomycosis, an infection due to the Streptothrix 
actinomyces, usually develops in the lower jaw; the upper jaw, tongue, 
fauces, lungs, or any part of the alimentary tract, especially the cecum 
and the liver, may be the primary seat of infection. 

The disease is characterized by dense nodulation, slow extension, a 
marked tendency to fistulization, and the discharge of pus containing 
granules in which the infecting organisms may be identified. It spreads 
by continuity of tissue, is slow in progress (months, years), and, in the 
case of the internal organs, is usually not suspected until the parietes are 
infiltrated and the sinuses or fistulas form. 

The distinction from tuberculosis is based on the tendency of the latter 
infection to invade the lymph glands, the results of tuberculin and 
laboratory tests. 

Anthrax. — Anthrax, observed in those who handle the hides, or the 
carcasses of animals which have been affected by the disease, develops 
on an exposed surface of the body as an acutely inflamed, painful 
pimple, which becomes densely indurated and is surrounded by a cluster 
of vesicles. These are regarded as characteristic. There is central 
sloughing and rapid extension of induration and edema. The symp- 
toms are those of acute sepsis. 

Diagnosis is made by examination of the blood, of the wound secre- 
tion, and finally by the excision of a small portion of the area of active 
infection and the examination of it for the anthrax bacillus. From car- 
buncle the distinction is suggested by the prompt skin necrosis and the 
rapid extension of the infection. The edematous form is characterized 
by a widespread swelling and multiple sloughs. 

Tetanus. — Tetanus, incident to the toxic action of the bacillus tetani 
and particularly likely to follow punctured and lacerated wounds in- 
fected by earth, is characterized at first by stiffness of the jaw and 
neck of such slight degree that the patient may give it little atten- 
tion. If the wound has involved the hand or foot, the corresponding 
extremity may first exhibit muscular stiffness. There follow fixation 
of the jaw, rigid extension of the' head and tonic spasm, the latter 
accompanied by clonic exacerbations, distorting the body and caus- 
ing asphyxia, which may be fatal in its completeness and prolonga- 
tion. The rapid progression and violence of the symptoms is usually 
inversely proportionate to the period of incubation, those developing 
within a week of the wound usually ending fatally. A prolonged incu- 
bation, two weeks or more, is often followed by spasm less frequent 
and less violent, with almost complete muscular relaxation during the 
interval. 

There is a form of tetanus occurring after infected head wounds char- 
acterized by unilateral facial palsy and spasm limited mainly to the 
muscles of the head and neck. 



INFLAMMATION 77 

The diagnosis of tetanus is based upon the presence of an infected 
wound, the development of the characteristic symptoms, and often upon 
finding the specific bacillus in the wound. 

Hydrophobia, or Rabies. — Hydrophobia incident to the bite of a 
rabid dog, wolf, or other animal and occurring after an incubation period 
which should average forty days is characterized first by depression, 
restlessness, and apprehension, and often by pain or hypersensitiveness 
in the region of the wound. Thereafter follow for some days stiff neck 
and difficult deglutition, with the development of spasm confined to the 
neck and jaw muscles, and brought on or aggravated by efforts at swal- 
lowing. Hallucinations, delirium, recurring throat spasm, and finally an 
ascending palsy are the characteristic features of the affection. It is 
distinguished from tetanus by the difference in etiology and by the 
general spasms of the latter condition, which especially involve the 
muscles of respiration. Moreover, tetanus in its virulent form has a 
short incubation period. 

When a psychic hydrophobia attacks one not familiar with the true 
symptomatology of the infection, it is characterized by an incubation 
period too brief to be real and the sudden onset of symptoms correspond- 
ing in type with the popular impression of the disease rather than its 
terrible reality. 

Glanders. — Glanders, an infection by the Bacillus mallei, observed 
in those who handle horses or other aquidse, is characterized by a pre- 
liminary typhoidal state with discharge from the nose, the symptoms of 
bronchopneumonia of slight or moderate severity, and the development 
of multiple hard swellings in the skin, beneath it, or in the muscles, 
which soften and break down, discharging a bloody pus. The consti- 
tutional symptoms are those of an active and progressive sepsis. The 
diagnosis is based on finding the specific bacillus in the discharge of 
the lesions. It is suggested by the usual occupation of those suffering 
from this infection, but is usually not suspected until the skin nodules 
appear. 

If the inoculation be through a skin abrasion or wound, this becomes 
converted into a destructive ulcer, usually of small size, with lymphatic 
involvement. The red skin nodules constituting the farcy buds appear 
later. 



CHAPTEE IV. 

COMPLICATIONS AND SEQUELS OF TRAUMA. 

Shock. — Shock, a condition of vasomotor paresis, mainly incident 
to trauma, often accentuated by the psychic state, is characterized by 
pallor, subnormal temperature, muscular relaxation, shallow, irregular 
breathing, often hurried in rhythm and interrupted by long deep breaths, 
low blood pressure, and a running pulse. The mentality is lethargic, 
the skin moist, the face expressionless, the pupils moderately dilated; 
nausea, vomiting, and incontinence of urine are often present. There 
is an erethistic form characterized by uncontrollable restlessness and 
delirium. 

Shock is especially pronounced in burns, acute perforation of the 
stomach with rapid escape of contents, acute hemorrhagic pancreatitis, 
and injury to the central nervous system. In peripheral crushes it is 
usually proportionate to the amount of tissue involved. There is an 
extraordinary individual variation of susceptibility to this condition. 

The shock of operation is usually proportionate to the duration of 
exposure, extent of traumatism, and particularly the quantity of blood 
lost. 

The sudden death which occurs in consequence of testicular injury, 
incarcerated or strangulated hernia or efforts at its reduction, tapping 
of pleural exudates, or the passing of a stomach tube, is probably due 
to cardiac inhibition. 

Hemorrhage. — Hemorrhage is characterized by rapid, feeble pulse, 
irregular, shallow respirations, with recurring deep sighing inspiratory 
effort, pallor, sweating skin, blanched lips, air hunger, thirst, often 
uncontrollable restlessness, failing vision, tinnitus, unconsciousness, and 
convulsions. The symptoms are those of shock; the two conditions are 
often associated. The diagnosis is dependent upon the history; in 
case of internal bleeding, by the progressive severity of symptoms in the 
absence of adequate cause, and the demonstration of a fluid effusion 
into the peritoneal or the pleural sac or into the gastro-intestinal canal, 
as shown by vomited blood or that passed per rectum. 

Postoperative Vomiting. — Postoperative vomiting may be absent, 
slight and transitory, or persistently recurring, usually exhibiting a 
definite relation in its severity to the skill of the etherizer. When the 
patient has been properly prepared the vomitus is of glairy mucus, not 
infrequently containing streaks of blood from the throat, and smelling 
strongly of ether. Later there is a bile admixture. In the course of the 
first twelve hours this vomiting practically should cease. When it is 
prolonged for more than twenty-four hours, and particularly when it is 



COMPLICATIONS AND SEQUELS OF TRAUMA 79 

frequently recurring it is symptomatic of either deficient hepatic met- 
aboHsm (acidosis) or renal elimination, or, if an abdominal operation has 
been performed, it suggests acute gastric dilatation or mechanical or 
dynamic ileus. 

Defective liver metabolism is evidenced by the presence of acetone 
and diacetic acid in the urine. In its more pronounced form coma 
develops. In this relation it is worthy of note that a latent diabetes may 
be made active by operative procedure and may cause fatal coma even 
though the wound run a clean course. 

The vomiting of ileus or acute gastric dilatation is accompanied by 
the characteristic symptoms of these conditions. It is usually regur- 
gitant in type, and is profuse, offensive, and brown in color. 

Pressure palsies are first observed when the patient recovers from 
ether. The brachial plexus or some of its branches are commonly in- 
volved, usually due in the former case to prolonged Trendelenburg 
position, with the forearm hanging above the head (pressure of the 
clavicle), in the latter to resting the arm on the edge of the table (ulnar, 
musculospiral). 

Postoperative Complications of Celiotomy .^Some complications 
are peculiar to abdominal operations, others follow them more frequently 
than they do operations on other portions of the body. 

In the first twenty-four hours after celiotomy there is always local, at 
times general atony, characterized by feeble peristalsis, general tympany, 
and pain and tenderness incident to the peritoneal reaction against trau- 
matism; the pulse is not markedly affected. This condition is usually 
transitory, audible peristalsis, colicky pain, and the passage of flatus, 
denoting the return of intestinal tonus on the second or third day. 

Exceptionally immediately after operation, and as the result of rough 
manipulation, prolonged exposure, and inadequate preparation, the 
gastro-intestinal atony is associated with a distention so great as to con- 
stitute dynamic ileus (p. 481). Ether vomiting is succeeded by that 
characteristic of ileus, the pulse becomes rapid and feeble, and the 
breathing hampered by upward pressure against the diaphragm. Neither 
the severe pain, great tenderness, nor muscular rigidity of diffuse perito- 
nitis are present. 

Dynamic ileus, developing on the second or third day after operation, 
is usually incident to diffuse peritoneal infection. 

Acute gastric dilatation, a local form of dynamic ileus, coming on 
immediately after operation or days later can be recognized as such 
only in the early stages when the tympany is mainly epigastric and 
peristalsis not yet abolished, unless the great relief obtained by gastric 
lavage can be considered characteristic. 

Postoperative diffuse peritonitis is characterized by a steady increase 
in postoperative pain, a progressive rise in the pulse rate, a temperature 
higher than that characteristic of normal wound reaction and the tender- 
ness and muscular rigidity of peritonitis associated with absent peristalsis, 
tympany, regurgitant vomiting, and absolute constipation (p. 482). 
Postoperative mechanical obstruction and strangulation exhibit the 



80 COMPLICATIOES AND SEQUELS OF TRAUMA 

symptoms of these conditions as they occur in the absence of operation 
(p. 482). 

Postoperative phlebitis, probably an expression of mild infection, 
develops in the second week after abdominal section, and involves 
most frequently the left femoral and the long saphenous vein. Pain, 
fever, and leukocytosis are accompanied or followed by the detection of 
a tender indurated cord occupying the position of the vein. Throm- 
bosis and phlebitis of intra-abdominal veins can be recognized only by 
exclusion. 

Pneumonia is comparatively rare when the anesthesia is intrusted 
to skilful hands and the after treatment of patients is conducted in 
rooms and wards in which pneumonia cases are not treated, except in 
its embolic form, and is characterized by moderate fever and pulse hurry, 
rapid breathing, localized signs of consolidation, and at times slightly 
blood-stained expectoration. When lobar or lobular, it conforms to 
type. Pneumonia, bronchitis, and pleurisy are observed more frequently 
after abdominal than after other operations even when local anesthesia 
is used. 

Parotitis, characterized by local swelling, tenderness, and pain, is 
more frequent after abdominal operations, particularly those involving 
the pelvic organs, than after peripheral ones. It may be chronically 
inflammatory in type or acutely suppurative (p. 302). 

Hematemesis is an expression of profound blood dyscrasia, rare as a 
postoperative complication, but less so after operation in the upper 
abdominal segment than after intervention in other regions. It follows 
the usual postanesthesia vomiting immediately, after a short interval, or 
not for days ; it is regurgitant in type, black and acid, not very profuse, 
and is attended by the constitutional symptoms and the facies of pros- 
trating toxemia. It may be associated with blood in the stools and 
subcutaneous bleedings. 

Sudden Death Occurring after Operation.— Aside from death 
due to shock, hemorrhage, sepsis, colossal pulmonary thrombosis, fat 
embolus (p. 97), myocarditis, acute dilatation of the heart, uremia, 
acute fatty degeneration, and a few other well-recognized conditions 
with fairly characteristic symptomatology, there remain to be explained 
certain fatalities which occur suddenly in the midst of an apparently 
smooth convalescence and with premonitory symptoms entirely wanting. 
Death may be incident to a sudden change in posture or muscular effort, 
and may be preceded by only a few seconds of agony. In such cases 
colossal pulmonary embolus or the final overwhelming of a dilated heart 
are regarded as adequate causes, as they are, though pulmonary embolus is 
not immediate in its effect and a myocarditis with dilatation and impend- 
ing breakdown should have given warning symptoms. At autopsy 
neither of these conditions, nor coronary embolus, nor adequate heart 
lesion, nor bulbar thrombus has been found. 

Death may occur during sleep without change in posture or other sign 
aside from respiratory arrest. In the case of one patient convalescent 
from sunstroke and sleeping quietly, with normal pulse and tempera- 



COMPLICATIONS AND SEQUELS OF TRAUMA 81 

tiire, the death pallor was seen to sweep over his face, the respiration and 
the heart stopping apparently at the same moment. In this ease a small 
clot was found in the wall of the fourth ventricle. 

In some cases such an apparently causeless death seems to be asso- 
ciated with the condition termed status lymphaticus, characterized by 
enlargement of all the lymphatics and the thymus gland and a general 
flaccidity of tissue, though the fatality in this condition is more likely to 
occur during the administration of an anesthetic, particularly if this be 
chloroform. 

Iodoform Poisoning. — Iodoform poisoning in its acute form, char- 
acterized by a fatty degeneration of the heart, liver, and kidneys, and at 
times edema of the brain, is characterized by irregular, rapid, feeble pulse, 
nausea and vomiting, or at least absolute distaste for food, headache, 
sleeplessness and psychical depression, or even active delirium. In severe 
cases coma may develop. This sometimes may follow shortly after the 
first dressing or injection, or may be delayed some weeks, developing only 
after repeated applications of the drug. Where this has been used 
judiciously the appearance of toxic symptoms must be attributed to an 
idiosyncrasy. 

The diagnosis should be based on the apparently causeless circulatory 
failure, associated with cerebral symptoms, and upon the fact of absorp- 
tion as attested by the presence of iodine in the urine. The diagnosis is 
usually confirmed by the beneficial effect of withdrawing the drug as a 
dressing, though the systemic improvement may be slow. Chronic 
poisoning may be manifested by wasting, complete distaste for food and 
symptoms of acute poisoning expressed in a mild form, the characteristic 
feature, however, being persistently rapid pulse. 

Mercurial Poisoning. — Mercurial poisoning is characterized by 
salivation, vomiting, bloody diarrhea, and blood and albumin in the 
urine. The examination of the urine will show the presence of mercury. 



CHAPTER V. 

TUMORS. 

Tumor, by which is meant a functionless independently growing 
tissue hyperplasia, may be generally classed under the headings benign 
and malignant. 

The benign tumors, at times multiple in their beginning, are usually 
of slow growth, are characterized by the presence of an investing capsule, 
the absence of lymphatic involvement, failure to recur after complete 
removal and are innocent of hurtful effect, except that of mechanical 
pressure incident to their position. 

Malignant tumors, rarely multiple in their beginning, are usually of 
rapid growth, are characterized by the absence of distinct capsules, a 
tendency to infiltrate the surrounding tissues, to involve the anatomi- 
cally associated lymph glands, to recur after complete removal, and to 
become disseminated through the system by either the lymphatic or the 
blood channels. They are ultimately lethal. 

Rapid growth of an obviously benign cyst or tumor, if not adequately 
accounted for by trauma or inflammation, should be regarded as sugges- 
tive of malignant transformation. 

The general symptoms of tumor independent of its benign or malig- 
nant nature are those of pressure and the formation of a mass. In the 
early stages of growth neither skilled palpation nor long experience can 
always determine whether this mass is benign or malignant. When the 
diagnosis is certain because of infiltrations, glandular involvement, 
and metastases, the time for intervention has passed. It would, therefore, 
seem logical to diagnosticate all tumors which are not obviously benign, 
which are small and progressively increasing in size, and have recently 
developed, by wide removal and microscopic examination. 

Tumors which have existed for years without marked change in size, 
without metastasis, or influence on general health, are obviously benign. 
Superficial lipomata and angiomata, multiple osteomata and osteochon- 
dromata of the growing period, papillomata and certain of the fibromata, 
adenomata, dermoids, and many of the cysts present features so typical 
that they can be recognized at once as benign. Any of these tumors 
may undergo malignant degeneration, first evidenced by rapid growth. 
The diagnosis under such circumstances, if inflammatory and traumatic 
causes be excluded, should be made by wide excision. 

If the infections can be excluded, particularly the syphilitic and the 
tuberculous, all persistent and apparently causeless ulcerations of the skin 
or of the accessible mucous membranes occurring in an otherwise fairly 
healthy person should be diagnosticated in the early period of their devel- 



TUMORS 83 

opment by wide excision and microscopic examination. From this 
general rule leg ulcers and those which are prevented from healing by 
lack of cleanliness and recurring irritation should be excluded. 

This same rule in regard to diagnosis by early excision holds true in 
regard to tumors of the muscle and tendons and to those of the bone. 
In the latter case the early symptoms are expressed in the form of pain. 
If this be persistent, well localized, increasing in severity and without 
apparent cause, and, if the .T-rays show a circumscribed area of rarefaction 
or absorption, the diagnosis should be made by exploratory operation. 

Tumors of the intra-abdominal organs have usually reached such 
size before they can be detected by palpation or can be suspected from 
obstructive or pressure symptoms that, if malignant, the favorable time 
for intervention has passed. 



CHAPTER VI. 

THE SKIN. 

BuLKLEY, in an analysis of 20,000 cases of skin diseases, notes that 
the commonest affection is eczema, about 30 per cent. Next in order 
of frequency comes acne, 16 per cent. Next, syphilis, 12 per cent. It 
follows that nearly two-thirds of all patients who present themselves with 
skin lesions are affected with one of these three diseases. Psoriasis, 
the eruptions due to phytoparasites (tinea), zooparasites (pediculus, 
acarus, etc.), and urticaria come next in order of frequency. 

Fig. 28 




Acne vulgaris. (Hartzell.) 



Eczema. — Eczema is the term applied to a chronic skin inflammation 
of unknown etiology which is characterized by infiltration, usually 
exudation, exhibits a tendency to persist or recur, and is attended by 
itching and burning. It may appear in the erythematous, papular. 



PLATE IV 




Papular and Papulopustular Syphilides. 

Early secondary (mouths). No subjective sjTQptorus. Patient feeling well. 



PLATE V 




Eruption universal. 



Early (Months) Secondary Syphilides. 

Lesions macular, papular, and papulopustular. Coppery red, neither painful 
nor itching. Patient feeling well. 



i 



THir SKIN 



85 



vesicular, or pustular form. It exhibits remissions, intermissions, 
relapses, and exacerbations without apparent cause, is not ulcerative or 
destructive in its tendency, and often is closely related to gastro- 
intestinal disturbances and error in diet. 

Acne. — ^Acne (pimples), a chronic inflammation of the sebaceous glands 
and the periglandular tissue, occurring during adolescence and affecting 
by preference the face, back, and chest, is characterized by the appearance 
of usually multiple red papules, nodules, or pustules. There are few 
subjective symptoms. The individual papules may often show the 
black centres characteristic of comedones, and the latter are usually 
abundantly distributed over the surfaces involved. 

The black point of the comedo represents the dried secretion of a 



sebaceous gland. 



Fig. 29 




Gumma of back. Duration, months. No subjective sjTiiptoms. 



Syphilitic Skin Lesions. — ^The manifestations of the secondary stage 
of syphilis are widespread, superficial, non-destructive, polymorphous, 
rounded in shape, slightly desquamative, raw-ham colored, without 
subjective syniptoms, and exhibit either the history of a primary lesion 
or the scar and often the glandular involvement of its one-time presence. 
An examination of the serum obtained by attrition and cupping of these 
lesions will show the presence of the spirochete. Destructive lesions 
occurring early are characteristic of a virulent infection. 

Tertiary lesions, single, grouped, or symmetrically disposed, appear 
as painless, infiltrating, rounded, coppery red lesions which exhibit a 



86 



THE SKIN 



tendency to ulcerate and which leave permanent pigmentation and scars. 
When the individual lesions become confluent the resultant ulcer exhibits 
circinate borders often with central healing and scar formation. If 
glandular involvement occurs, this is incident to mixed infection. The 
diagnosis strongly suggested by the indolent, painless, rounded lesions 
is corroborated by the history and by the clinical test for syphilis. 

Psoriasis. — Psoriasis is characterized by the development of rounded, 
distinctly defined, slightly elevated, red, non-ulcerating papules, often 
symmetrically distributed on the two sides of the body and exhibiting a 
preference for the extensor surfaces of the elbows and knees. These 



Fig. 30 




Typical cicatrix of tertiary skin lesions. Soft, irregularly pigment non-adherent scar, 
with rounded outlines of the original grouped lesions. 

papules exhibit no tendency toward ulceration, but are often covered by 
an imbricated crust of silvery white epithelial scales. The individual 
lesions vary from the size of pinheads to that of a half-dollar, and by 
coalescence may form irregular patches. The condition is an extremely 
chronic one. The exfoliation is a characteristic feature. The distinc- 
tion from syphilis must at times be based on the history and the results 
of specific treatment. 

Of the phytoparasitic eruptions, tinea favosa, tinea trichophytina, 
tinea versicolor, and erythrasma are the forms commonly encountered. 

Tinea Favosa. — ^Tinea favosa, a contagious affection commonest in 
infancy and childhood, is characterized by the formation of thick, yellow- 
ish, brittle crusts of mouse-like odor, occurring in rounded or irregular 



THE SKIN 



87 



patches upon the scalp. The hair of the involved region is brittle, 
stubbed, broken, and exfoliated. The crusts, when not disturbed, exhibit 
a characteristic cupping. 

Diagnosis is based on the finding of the Achorion schonleinii. 

Tinea Circinata (Ringworm). — ^Tinea circinata, as it occurs upon the 
body, forms usually typical red annular lesions, which begin as small 
papules. At times concentric rings are observed and sometimes vesicu- 
lation. Even if the circle be broken the outline is generally crescentic. 
The diagnosis is based on the findings of the Trichophyton tonsurans. 



Fig. 31 



'J^ 


. ^ 




'W 


% 


i^m^ K 








"^ 






^■■'"»^;^H 




^ mm 




i 


#^ ■ ' ;^^ 



Tinea favosa (scalp). 



Tinea Tonsurans. — ^Tinea tonsurans, the expression of scalp invasion 
by the same parasite, appears in the form of rounded scaling skin patches, 
in which the hair is stubbed, broken, and exfoliating. The diagnosis is 
made by finding the parasite. 

Exceptionally tinea tonsurans may cause a distinct boggy scalp 
tumor made up of multiple small abscesses exuding a gummy secretion. 

Tinea Sycosis. — Parasitic sycosis, due to the same infecting agent but 
appearing upon the bearded face, is characterized at first by small 
erythematous or edematous rings and brittle broken hairs and stubs. 



THE SKIN 

Fig. 32 




Tinea circinata. Fungus demonstrated. (Hartzell.) 



Fig. 33 




Tinea cruris. (Hartzell. ") 



THE SKIN 



89 



Later, by a diffused skin inflammation, exhibiting papules and pustules 
and discharging a sticky purulent exudate which crusts. 

The distinction from non-parasitic sycosis is made by finding the 
Trichophyton tonsurans. 

Tinea Versicolor. — ^Tinea versicolor appears in the form of extensive 
patches of pigmented, slightly scaling skin, usually on the anterior sur- 
face of the chest, sometimes involving the greater portion of the surface, 

Fig. 34 




Tinea tonsurans (negro). 



which is protected by the clothing. Pigmentation is the only feature 
which attracts attention. The diagnosis is made by finding the Micro- 
sporon furfur. 

Erythrasma. — Erythrasma is the term applied to a hyperemic discolora- 
tion appearing in the form of red or brownish patches on surfaces sub- 
ject to prolonged skin contact and slight friction, such as the gluteal 
fold, about the axilla, beneath the breast, and on the inner upper surface 
of the thigh. The diagnosis is based on finding the Microsporon minu- 
tissimum. 

Pediculi. — Pediculi may cause lesions varying from a slight erythema- 
tous patch, with a punctate centre, to multiple superficial pustulization 
with the formation of thick crusts. 



90 



THE SKIN 



The diagnosis of the presence of the head louse is made by finding 
the nits glued to the hair in the area of preference, i. e., the occipital region. 

Body lice are always indicated by the excoriations of universal scratch- 
ing, usually associated with minute red points indicating recent puncture. 

Pubic lice lead to violent itching in the pubic region, and the lesions 
of scratching, which are to be seen on inspection, together with the 
nits attached to the hairs. 





Fig. 35 


i 


'. 


;^H 




Ifl 




s 


^^^HH^^^v^*^^^^^^! 






^^ 


^M 



Tinea sycosis. (Hartzell.) 

Scabies, or Itch. — Itch appears as a papulopustular eruption, most 
pronounced in the interdigital folds, the axilla, and on the wrists, thighs, 
and abdomen. It is attended by intense itching, particularly at night, 
and often out of proportion to the extent of the lesion. Diagnosis is assured 
on finding in an unscratched region a characteristic tunnel and made 
absolute by extracting the Sarcoptes scabiei therefrom with a fine needle. 

Urticaria. — Urticaria, often accompanied by fever, is characterized by 
the sudden or rapid development of small or large burning or itching 
wheals, which may disappear as rapidly as they come. 

Closely associated with this condition is angioneurotic edema, in which 
circumscribed soft swellings are produced either in the form of nodes 
on the surface or edematous infiltration of regions such as the lip, the eye- 



THE SKIN 91 

lid, the glottis, or internal organs. Such an edema may be attended by a 
rapidly developing and dangerous asphyxia. Its internal manifestations 
are sometimes evidenced by typical symptoms of acute intestinal obstruc- 
tion (p. 481). It is not infrequently associated with purpuric eruption 
and with the joint manifestations commonly regarded as rheumatic. 

The affections of the sweat glands characterized by excess, deficiency, 
or perversion of secretion are sufficiently obvious. 

Miliaria, or prickly heat, usually associated with hyperactivity of the 
sweat glands, is characterized by the development of a multitude of 
minute vesicles upon a reddened, stinging, burning skin. 

Cysts of the coil duct occasionally appear upon the surface, usually 
of the face and nose, in the form of non-inflammatory, tense, round, 
translucent vesicles. 

Fig. 3G 




Itch. (Hartzell.) 

Disorders of the sebaceous glands are usually expressed in the form 
of seborrhea, acne, or comedone. 

Seborrhea. — Seborrhea, exhibiting a preference for the scalp, face, and 
genital regions, may appear either as an oily exudate or more commonly 
as a greasy scaling which sheds freely. The distinction from tinea, when 
it appears in patches with slight inflammatory symptoms, is made by the 
microscope. 

Milium, common in infants and presenting the appearance of minute 
white skin-embedded seeds (p. 260) and wens (p. 240), are described 
elsewhere. 

Erythematous skin lesions are common manifestations of toxemia 
and infection. They develop rapidly as irregularly shaped red patches, 
often of large size. The eruption may closely resemble that of scarlet 
fever, but is unattended by the pronounced throat symptoms, and des- 
quamation begins in a few days. 

Herpes (p. 259), erysipelas (p. 75), erysipeloid (p. 360), furuncle 
(pp. 245, 360), carbuncle (p. 245), and anthrax (p. 76) are described 
elsewhere. 



92 



THE SKIN 



Sycosis. — Sycosis due to the ordinary staphylococcic infection appears 
on the hairy part of the face in the form of papular, papulopustular, and 
nodular lesions, which by coalescence produce disfiguring patches. The 
distinction from tinea sycosis (barbers' itch) is made by microscopic 
examination. 




Sycosis vulgaris. (Hartzell.) 

Impetigo. — Impetigo, at times an epidemic and apparently contagious 
pus infection, appears on the face of young people in the form of a 
vesicular eruption followed very shortly by rupture of the vesicles and 
the formation of thin, flat, brown crusts. The lesions are disseminated 
rather than grouped. There are few subjective symptoms, and the 
affection is self-limited. 



THE SKIN 



93 



Pityriasis Rosea. — Pityriasis rosea is of importance to the practitioner 
because it bears a close resemblance to lesions of secondary syphilis. 
The lesions are maculopapular, rounded or annular in shape, and exhibit 
a tendency to fine scaling. The distinction from syphilis is based on the 
history, on the results of treatment, and carefully conducted examination 
of the serum obtained by attrition and cupping of a lesion for the spiro- 
chete. 

Lichen .^Lichen is a chronic affection exhibiting a predilection for the 
flexor surfaces of the forearms and appearing in the form of small, flat, 
clearly defined angular papules, exhibiting a polished red surface. These 
papules coalesce, forming angular patches. There is usually slight 
desquamation and much itching. 



Fig. 38 




Lichen planus. Several years' duration. (Hartzell.) 

Purpura. — Hemorrhage of the skin of non-traumatic origin is usually 
an expression of pronounced toxemia. Its first appearance suggests an 
erythema, but the color cannot be made to fade by pressure. Shortly 
the characteristic discoloration of efi^used blood becomes manifest. 
Small spots are termed petechise; larger ones are termed ecchymoses. 
Exceptionally the blood effusion may be so pronounced as to form bullae. 
Lesions are usually most pronounced in the lower extremities. 

When the purpuric eruption occurs in the course of fever, or is associated 
with arthritic pains and swelling, the term rheumatic purpura is applied 
to it. It is not infrequently associated with urticarial lesions, gastro- 
intestinal crises, or bleeding from the kidneys. 

Of the hypertrophies, lentigo, or freckles, chloasma, or patches of dis- 
coloration termed liver spots, keratosis, or horny thickening, moUuscum 
contagiosum, corns, and warts will be mentioned in discussing the 
regions of predilection. 

Keloid. — Keloid, usually of traumatic origin, is characterized by an 
irregular white or pink nodulation with claw-like extensions into the 
surrounding skin, usually painless, sometimes itching intensely, and 
often distinctly vascular. The seat of predilection is the skin over the 
sternum. 



94 



THE SKIN 



Of the slowly ulcerating and destructive skin affections, those due to 
tuberculosis and syphilis are of major moment. 

Lupus Vulgaris. — The primary tuberculous skin affection usually 
begins in early youth by the formation of red, raised, soft, jelly-like 
nodules which by confluence and peripheral growth form destructive 



Fig. 39 




Fibroma molluscmn. Smaller lesions are sessile and overlying skin tmaltered. Larger lesions 
peduncxilated and lobulated. Skin is thinned and adherent. Neoplasms consistency of soft wax. 
(Duhring's service: Carnett.) 



lesions. The common seat is the face. The progress is extremely slow. 
There is cicatrization of one part while the ulcer is extending both 
superficially and in depth in another. 

The diagnosis is based upon the presence of the reddish jelly-like 
lupoma and the results of microscopic examination. 

Lupus Erjrthematosis. — ^This appears as a persistent erythema, often 
associated with seborrhea and branny desquamation. Neither nodules 
nor crusts develop and the lesion is very commonly symmetrical, forming 
patches on either cheek, with a ridge across the nose connecting them. 
This affection develops at a later period of life than lupus. 



PLATE Vr 




Senile Keratosis Epithelioma. (Hartzell.) 



PLATE VII 




Pemphigus. (Hartzell. 



i 



THE SKIN 



95 



Sarcoma. — Sarcoma of the skin may Fig. 40 

be solitary or multiple. In its pigmented 
form it often originates in an irritated 
nevus. Some forms of the multiple in- 
filtrating sarcomata exhibit a tendency 
toward self-limitation. In case of a single 
growth the diagnosis should be made by 
excision and examination. 

Sarcoma of the skin may appear shortly 
after birth in the form of flat, hard, or soft 
nodules, exhibiting rapid growth. 

In later life the affection may develop 
in the form of a hard tumor, which can- 
not be distinguished from fibroma and 
which may remain dormant for years. 

Exceptionally the tumor is formed with 
such rapidity and with such hyperemic 
symptoms as to suggest a subacute 
abscess. 

Epithelioma. — Epithelioma begins as a 
persisting inflamed patch of keratosis 
pigmentation or papillary outgrowth, 
often as a slight trauma which refuses 
to heal. 

The rodent ulcer type is usually placed 
on the face above the level of the nostrils ; 
the fungating type affects particularly the 
lower lip of males. 

Syphilis as a causative factor must be 
excluded. The rapid growth and prompt 
adenopathy of chancre, the multiplicity 
and polymorphism of secondary lesions 
are characteristic. Tertiary lesions are 
usually grouped rather than single, nor 
are their regions of predilection usually those of epithehoma. They 
begin as infiltrations rather than ulcerations. 

The diagnosis should be made by wide excision of persistent small 
ulcerations occurring in those past middle age. 




Lupus vulgaris. 
Duration, years. (Hartzell.) 



CHAPTER VII. 

THE BLOODVESSELS. 

As the result of trauma a bloodvessel may be contused or partially or 
completely ruptured. The contusion, in case the inner coats have been 
ruptured or distinctly injured, is followed by thrombosis, characterized 
by loss of distal pulse if arterial, peripheral congestion and edema if 
venous, and local tenderness and swelling. If the thrombus becomes 
acutely infected, abscess will develop, and may be followed by secondary 
hemorrhage or septic embolism. Partial rupture may be followed by 
aneurysm. 

Wound or rupture involving all the coats of a bloodvessel is followed 
immediately by blood extravasation, characterized by the rapid forma- 
tion of a fluctuating tumor which may pulsate if a large artery be in- 
volved. If the bleeding be into the pleura or peritoneum, the symptoms 
are those of progressive hemorrhage with the evidence of free fluid in the 
thoracic or the abdominal cavity. Bleeding into the brain is characterized 
by pressure symptoms. 

Arteritis. — The effects of inflammation of the arterial walls are 
lessened elasticity and power of vasomotor response, diminution in 
caliber, the formation of thrombi, and such weakening as to favor 
the development of aneurysm. Trauma and the infections, particularly 
the staphylococcic, streptococcic, syphilitic, typhoid, and rheumatic, are 
the usual causes. 

The local symptoms are expressed in the form of hardened arteries, 
diminished nutrition, hence lessened vitality and impaired or altered 
function, the symptoms of thrombosis and embolism, and aneurysm. 

Phlebitis. — Phlebitis, due to a trauma or infection, often of unknown 
origin, is expressed in the form of venous thrombosis, usually non-sup- 
purative and characterized by fever and leukocytosis and the develop- 
ment of a painful, tender, cord-like swelling along the course of the vein, 
with dusky and edematous swelling of the overlying skin in the case of a 
superficial vein, or pronounced edema of the parts from which the vein 
carries the blood in the case of a deep one. 

The left femoral vein is the favorite seat of thrombosis. Typhoid 
fever (third week), abdominal operations (convalescent period), pneu- 
monia (postfebrile stage), and childbirth are predisposing causes. 
Superficial varicosities and lymphedema are sequelae. 

Thrombosis and Embolism. — ^Thrombosis inevitably follows wounds, 
nor is it unusual after clean operations for small emboli to be carried to 
the lungs. These, if not infected, occasion few symptoms aside from 
slight cough and moderate and transitory pleuritic pain, usually on the 
right side, attended by the detection of friction sound on auscultation. 



THE BLOODVESSELS 97 

An embolus so placed as to produce an infarct of some size causes 
more pronounced symptoms, together with a bloody expectoration. 
Such infarcts are common after operation on incarcerated and strangulated 
hernias. 

When an embolus lodges in the pulmonary artery or one of its major 
branches, symptoms develop at once, characterized by sudden and 
urgent dyspnea, tumultuous heart action, pale face, and usually dilated 
pupils. This attack may terminate fatally in a few minutes, or partial 
recovery may take place, followed by a new crisis. The diagnosis is based 
on the history of a recent severe traumatism, operative or otherwise or 
on the presence of a venous thrombosis. 

The symptoms of fat embolus are similar, but often less violent in 
onset. There is shock, violent dyspnea, cyanosis, cough, often blood- 
stained sputum, sometimes cerebral excitement characterized by delirium, 
or torpor or coma. There is a general elevation of temperature, a rapid 
small pulse, irregularity of the heart action. 

If the patient lives long enough for the test to be made, fat will be found 
in the urine. Fat embolism commonly follows injury to bone, particularly 
that largely involving the cancellous structure. 

Thrombosis of the internal jugular vein, usually secondary to middle 
ear infection and sinus thrombosis, is characterized by a tender indura- 
tion along the course of the vessel and pain increased on motion. 

Thrombosis of the hemorrhoidal veins is characterized by pain, 
swelling, and sphincterismus. The severe pain of sudden onset, called 
an attack of piles, is due to rupture of a vein and blood extravasation. 

Thrombosis affecting the deeper veins, characterized by pain, fever, 
and leukocytosis, can scarcely be diagnosticated unless there be an 
accompanying suggestive superficial thrombosis. Such complication 
occurring in the abdomen following operation, or in the course of typhoid 
fever or pneumonia, may simulate an acute peritonitis. 

Thrombosis of the superior mesenteric vein is less common than an 
embolic blocking of the same artery which it may accompany, is 
characterized by similar symptoms. 

Septic thrombosis incident to acute progressive infection is character- 
ized by the symptoms of thrombosis with those of abscess added thereto. 
It is an occasional cause of deep abscesses in the lower extremity. It is 
the usual cause of abscesses developing in regions remote from the seat 
of original infection and having no direct lymphatic connection therewith. 
Infection thus carried finds lodgement first in the lungs or, if it be derived 
from the collecting branches of the portal circulation, in the liver. 

Chill, fever, and sweat, irregularly recurring, and profound systemic 
depression are the constitutional expressions of such transferred infections 
with the symptoms of pylephlebitis, bronchopneumonia, or, if the throm- 
bus be carried beyond the lung capillaries and lodged elsewhere, local 
abscesses. 

The kidney is a favorite seat of lodgement for thrombi, resulting, if 
these be acutely infectious, in the formation of multiple abscesses at the 
seats of infarct and complete destruction of the organ. 
7 



98 THE BLOODVESSELS 

The acute osteomyelitis of adolescents may be similarly conveyed from 
a surface infection in itself of minor moment. 

Embolism of the mesenteric artery, secondary to endocarditis, or 
occurring in the course of infection, or without obvious predisposing 
cause, and at times associated with a thrombus of the mesenteric vein 
usually causes blood stasis and gangrene in the area of distribution (small 
intestines). The symptoms are sudden and are those of acute peritonitis 
(p. 478). A history of previous embolic attacks, or the presence of 
valvular heart lesions or a thrombosis elsewhere would be suggestive. 

Thrombosis or embolism of the peripheral arteries is characterized 
by the rapid or sudden failure of the peripheral circulation. There is 
severe pain, absence of pulse, and the part becomes cold, livid, painless, 
and, if collateral circulation is not established, gangrenous. Endocarditis 
with dislodgement of vegetations is the common cause of the larger 
peripheral emboli. The arterial block occurring in the course of 
infections may be embolic or thrombotic. 

Aneurysm. — Aneurysm, a blood sac which communicates with an artery, 
is due to a preexisting vascular lesion. Exceptionally it is traumatic, 
usually it is a consequence of arteritis. The affection is usual in middle- 
aged athletic Anglo-Saxons who have had syphilis and are alcoholic. 
The aorta, the popliteal, the femoral, the iliac, the subclavian, and the 
axillary artery are the ones commonly involved. Broca's formula reads 
to the effect that as one grows older supradiaphragmatic aneurysms 
become commoner and those beneath the diaphragm rarer. 

In shape the aneurysm may be fusiform, saccular, or distinctly loculated, 
and may be single or multiple. In its progression the aneurysm erodes 
both soft and hard tissues lying in the path of its enlargement, including 
the bones and joints; cartilage exhibits a greater resistance. 

The characteristic symptoms of aneurysm are the presence of a tumor 
in the region of an artery and fixed to it, which exhibits an expansile 
pulsation, thrill, and systolic bruit, which are abolished by proximal 
pressure. In the vessel distal to the dilatation a retardation and soften- 
ing of the pulse is noted, with weakening of impulse and absence of 
dicrotic wave. Pressure symptoms characterized by pain, venous con- 
gestion, and at times paralysis are marked. There is usually a steady, 
often intermittent, rapid growth. 

In spite of the complete symptomatology of aneurysm, the clinical 
distinction between this condition and other affections is not always 
made. 

When the sac becomes greatly thickened by deposit of laminated clots 
the characteristic aneurysmal symptoms may be slight or wanting. 
When the tissues around the aneurysmal sac become inflamed, either 
from rupture with slow leak or from infection, the resemblance to abscess 
is close. 

The distinction between aortic aneurysm and mediastinal tumor of 
other form is often made correctly only at postmortem. Nor are the 
a:-rays satisfactory in these difficult cases. 

On general principles the possibility of aneurysm should be carefully 



THE BLOODVESSELS 99 

considered whenever a tumor is placed near or upon a large blood- 
vessel. The history of the case, particularly a careful examination, 
and finally aspiration, will usually establish the diagnosis. 

Arteriovenous aneurysm, a persistent abnormal communication be- 
tween artery and vein, usually traumatic in origin, is an affection char- 
acterized by a soft, compressible, pulsating swelling exhibiting thrill 
and bruit and made up in large part of varicose veins. Pressure symp- 
toms are usually not so well marked as those characteristic of arterial 
aneurysm, though cramps, neuralgia, and anesthesia are common in 
arteriovenous aneurysm of the extremities. There is often an increase 
of growth in the affected part, sometimes a condition resembling elephan- 
tiasis; at times trophic changes and ulceration. The condition may be 
entirely lacking in subjective symptoms. 

Angioma. — A swelling made up of arterial varicosities is called cirsoid 
aneurysm; when the veins also are involved it is called aneurysm by anas- 
tomosis. These tumors (rare), exceptionally traumatic, form irregular, 
pulsating swellings beneath the skin, through which the tortuous ves- 
sels are readily seen. There is distinct thrill and bruit. The scalp is 
a favorite seat. 

Nevus, or birthmark, is the common form of angioma, appearing red 
or blue in accordance with the preponderance of arteriole or venule 
dilatation. It is congenital and often associated with lipomatous deposits. 
It may be markedly pigmented and may present extraordinary variation 
in surface configuration and color. Telangiectasis is a term applied to a 
dilatation of the skin capillaries acquired usually in adult life. The 
lesions are usually multiple, and may be widely diffused over the body, but 
are commonest on the face. Single tortuous vessels may appear; usually 
they are grouped. They develop in regions exhibiting the lesions of 
chronic acne or the infiltration of rapidly growing tumor. 

Cavernous angioma, exhibiting the structure of erectile tissue, forms 
soft, lobulated swellings, which exhibit marked variation in size incident 
to changes in venous pressure. Such a tumor may be mistaken for a 
cephalocele. The color and compressibility of the cavernous angiomata 
are the characteristic features. They may involve the greater part of an 
extremity, exhibiting in one part cystic formation, in another thick fibro- 
lipomatosis. The difference in size and tension incident to the position 
of the leg is characteristic. 

Gangrene. — Gangrene is essentially dependent on failure of the blood 
supply to the part. This may be due to traumatism which immediately 
and completely cuts off the circulation; to inflammation which occludes 
the lumen of the vessels by thrombus, aided in some cases by the direct 
pressure of the inflammatory exudate; to arteriosclerotic occlusion of 
the arterial lumen; to venous thrombosis producing stasis by back 
pressure; or to vasomotor spasm incident to disturbed innervation. In 
accordance with its cause gangrene is recognized as : 

1. Traumatic gangrene, due to crushing and destructive violence, 
prolonged devitalizing pressure or constriction, the action of heat, cold, 
or chemicals. It may be dry or moist, in accordance with the amount 



100 THE BLOODVESSELS 

of tissue involved and the completeness with which saprophytic and 
pyogenic bacteria are excluded. 

Acute spreading gangrene, particularly incident to lacerated contused 
wounds, may be due to the intensive action of the ordinary pyogenic 
organisms associated with the putrefactive and gas-forming germs, or to 
special infection by the bacillus of malignant or edema, the Bacillus 
aerogenes capsulatus. It is characterized by rapid extension of cellulitis 
beyond the area obviously involved, with the formation of gas in the 
tissues and the constitutional symptoms of profound sepsis. The nature 
of the infecting organism is determined by bacteriological examination. 

2. Embolic gangrene. If peripheral and involving large vessels the 
block is often at the bifurcation of the artery. The popliteal, femoral, 
and brachial are seats of predilection. The gangrene may appear in 
the dry form, affecting the fingers or toes, and may be followed by the 
moist form incident to secondary infection, involving the foot and leg. 

Thrombotic gangrene, if incident to trauma, would be suggested by 
the history and evidences of injury. If infective, the distinction from 
embolic gangrene would be difficult. 

3. Senile gangrene, predisposed to by arteriosclerosis, occasionally 
observed in the young, usually precipitated by an attendant trauma or 
slight infection of the part involved, or thrombosis at the seat of greatest 
arterial lesion, usually attacks the feet in the form of mummification. 

4. Diabetic gangrene is of the acute infective type, and is favored by 
tissues of poor resisting power and an associated arteritis and neuritis. 
It is characterized by the rapid sloughing and extension of a trifling 
infection, often by little or no pain. Except when associated with pro- 
nounced arteriosclerosis and directly dependent on this it appears in the 
moist form. 

5. Angioneurotic gangrene exhibits a predilection for young women, 
affecting particularly the fingers and toes, but occurring at times in 
symmetrical patches on the surface of the body. It is characterized 
by a preliminary causeless, extremely painful pallor, numbness and cold- 
ness, followed by slow necrosis. 

The symptoms of gangrene are those of local death, i. e., loss of pulse, 
heat, sensation and motion; livid, finally black, discoloration, with mummi- 
fication or putrefaction, always associated with vital depression, expressed 
in the form of acute or chronic sepsis. Whether the gangrene be of slow 
or sudden onset the initial symptoms are severe pain, lividity, loss of heat, 
loss of pulse, loss of sensation. The diagnosis is usually obvious. 

Following severe contusion there may be discoloration and vesica- 
tion which resemble gangrene. Preservation of pulse, of heat, of sen- 
sation, and a vitalized skin surface beneath the vesications establish the 
nature of the condition. 



CHAPTER VIII. 

THE LYMPH VESSELS AND GLANDS. 

Rupture of the Thoracic Duct. — If this occur without peritoneal involve- 
ment, it results in an extravasation of chyle which burrows downward, 
becomes sooner or later infected, and opens as a huge postperitoneal 
abscess in the groin, closely simulating in position and symptomatology 
psoas abscess. Associated with this condition there will necessarily be a 
rapid emaciation. Diagnosis in these cases has usually been made by 
the continued flow of chyle after evacuation of what was supposed to be 
a psoas abscess. 

The usual seat of wounding of the thoracic duct is at the root of the 
neck during extensive operations, such as removal of tumors from this 
region. The injury has been recognized at the time of operation by a 
continuous flow of chyle after the bleeding has ceased. Usually it is not 
suspected until an abundant flow of chyle fills a closely sutured undrained 
wound or flows from the drainage openings. 

Progressive wasting rarely follows, the circulation of the chyle being 
provided for by collateral channels. 

Lymphangitis. — Lymphangitis incident to infection may be acute or 
chronic. In its manifest form it is usually secondary to a virulent 
infection; it exceptionally develops after contusion or strain. It is 
usually associated with enlargement of at least the group of lymphatic 
glands into which the involved vessels empty. 

A general reticular lymphangitis involving the small divisions of the 
peripheral lymphatics is not an unusual sequel of infected wounds. 
Because of its resemblance to the eruption of scarlet fever it has beeln 
named surgical scarlatina. This eruption is local with an infecting focus 
for its centre, or, if otherwise placed, it appears in patches and not as a 
diffuse eruption, nor are the associated lymphatic glands generally 
enlarged. 

In its ordinary acute form, lymphangitis is characterized by rosy 
red, slightly edematous streaks corresponding with the position of the 
lymphatic vessels, accompanied shortly by enlargement of the asso- 
ciated glands. This acute form of infection may become suppurative, in 
which case nodular swellings, which shortly soften and discharge pus, 
are formed along the course of the vessels. Such suppuration is not un- 
usual in an acute lymphangitis accompanying chancroid and the wounds 
contracted in postmortem examinations. The resultant abscesses are 
characterized by an abundant thin, purulent discharge, which excep- 
tionally may be persistent and which may be increased by dependent 
position or by milking the parts. 



102 THE LYMPH VESSELS AND GLANDS 

In place of circumscribed abscess there is more likely to be developed 
general purulent infiltration of the surrounding cellular tissues. Suppura- 
tion of the deeper lymphatic vessels is characterized by the symptoms 
of acute cellulitis. 

The distinction between lymphangitis and phlebitis may be difficult. 
Velpeau stated that "phlebitis can be palpated, but not seen; lymph- 
angitis can be seen, but not felt" — a dictum which, though not accurate 
in its expression of fact, is suggestive as to the differentiation. 

Chronic lymphangitis may be an expression of either local or systemic 
infection. In its syphilitic form it is characterized by painless indura- 
tion of the vessel or vessels leading from a chancre to the associated 
group of lymphatic glands. Its usual position is on the dorsum of the 
penis, where it can be picked up from the skin and rolled between the 
thumb and finger as a hard cord. Palpable fine cords corresponding 
to the direction of the lymphatics are found in both the secondary and 
the tertiary manifestations of syphilis. 

Tuberculous lymphangitis has been observed most frequently as a 
sequel to the anatomical ulcer observed on the hands of dissectors. It has 
developed even when the focus of skin inoculation could not be demon- 
strated. The affection is characterized by induration extending along 
the course of the lymphatic vessels, slow (months) in development, 
persistent, and exhibiting a series of nodules which gradually soften and 
break down, forming multiple ulcers, superficial or deep in accordance 
with the position of the lymphatic vessel involved. There is usually 
enlargement and softening of the associated lymphatic glands. Since 
other chronic infections may produce these lesions, diagnosis must be 
based on the finding of the tubercle bacillus or on the results of animal 
inoculation and the tuberculin test. 

Malignant lymphangitis, characterized by painless, often nodular 
enlargements, is always associated with involvement of the lymphatic 
glands. It is usually obscured by the major malady. It can often be 
detected during operation. 

Lymphangiectasis. — Lymphangiectasis, or dilatation of the lymphatic 
vessels, may be congenital or acquired. 

The congenital form is usually manifested in infancy; it may not 
form an obvious swelling until later in life. 

Macrocheilia and macroglossia and lymphangioma of the neck and 
axilla are the usual expressions of congenital cystic dilatation of the 
lymphatic vessels. These conditions are commonly associated with 
hemangioma. 

Acquired lymphangiectasis due to obstruction, either extrinsic or in 
the vessel itself, and in the latter case usually incident to postinflamma- 
tory contraction, is commonest in the groin and genital regions, form- 
ing here at times a diffuse, soft, slowly growing tumor, which never 
reaches great size, which is lobulated, is distinctly varicose, and is to an 
extent movable upon the deeper parts and partly reducible. The con- 
volutions of the dilated vessels can often be seen on inspection and pal- 
pation, suggesting the sensation which is conveyed by a bundle of worms. 



THE LYMPH VESSELS AND GLAND3 103 

The latter distinguishes this condition from Hpoma, while translucency 
is highly characteristic when the vessels are so superficially placed that 
this sign can be elicited. Associated dilatation of the vein lower down 
is usually characteristic of venous varicosity in this position. 

Obstruction of the large lymphatic ducts, if the collateral circulation 
be insufficient, will cause not only lymphangiectasis, but also lymph- 
edema; or this condition may develop in the absence of obvious dilatation 
of the lymphatic vessels. 

Lymphedema. — Lymphedema is characterized by a brawny infiltration 
which in its ultimate development produces the condition known as 
elephantiasis. The overlying skin is thickened, often papillomatous, 
and subject to dermatitis. The subcutaneous tissues are those mainly 
involved. Ultimately the muscles atrophy. 

This condition may develop in any part of the body, but is commonly 
encountered in the leg and the scrotum. The obstruction causing it may 
be due to repeated inflammations, producing ultimate narrowing and 
obliteration of the vessels, to infiltration of the receiving glands (carci- 
noma and tuberculosis), or their removal, or to lodgement of the 
filaria. 

The diagnosis of the latter condition depends upon the associated 
hematuria and chyluria and the finding of the parasite in the blood. 

In its slighter development lymphedema is often associated with chronic 
leg ulcer. The difficulty in healing leg ulcers which are unassociated 
with other visceral disease or obvious venous dilatation is probably 
incident to retarded lymph circulation, due to a chronic lymphangitis, 
this condition not being sufficiently developed to cause obvious lymph- 
edema. 

Lymphadenitis. — The lymph nodes may be either acutely or chronically 
inflamed. 

Acute inflammation is usually due to the ordinary pus microbes and 
is characterized by the formation of one or more rounded tender swellings, 
over which the skin is movable, developing in the glandular group 
which drains an infected focus, and usually associated with mild 
symptoms of septic absorption. If the affection be virulent and de- 
structive, the nodule or nodules are quickly obscured by periglandular 
edema and abscess formation. Inflammation in the superficial glands 
offers no diagnostic difficulties. 

When the deeper glands are involved in acute suppurative inflamma- 
tion, the local and constitutional symptoms are simply those of deep 
phlegmon the glandular origin of which can be determined only by the 
position of maximum tenderness and swelling, the pain radiations, the 
interference with function, and the finding of a surface infection, which 
drains by the lymphatic vessels to the region involved. Such abscesses 
may burrow wide of their original seat. Deep local tenderness and infil- 
tration and superficial edema are the localizing symptoms which guide 
the diagnostic and curative incision. 

Chronic lymphadenitis, an occasional sequel of acute inflammation, 
usually the result of a continued and frequently repeated mild infection. 



104 THE LYMPH VESSELS AND GLANDS 

not infrequently tuberculous, sometimes syphilitic, is characterized by the 
enlargement and induration of a single gland or of an entire group, 
unattended by pain or local inflammatory symptoms, subject to recurring 
subacute attacks with rapid variations in size, terminating either in 
resolution or suppuration. 

Chronic Non-tuberculous Inflammatory Hyperplasia.^ — This is commonly 
encountered in the cervical and inguinal regions, less frequently in the 
axilla. In the cervical region it is usually secondary to infections of the 
nose, mouth, throat, or ear. In children, particularly when it involves 
the posterior group of glands, it is often due to head lice. 

The affection, if the cause is not removed, is slowly progressive and 
results in softening of individual glands and the discharge of an appar- 
ently sterile pus without inflammatory symptoms more marked than 
those needful for skin perforation. This softening takes place before 
the glands have reached the size of a pigeon's egg, and usually involves 
but a single gland. 

These cases of non-tuberculous chronic hyperplasia are rarely seen by 
the surgeon, since the enlargement is moderate and not progressive and 
the tendency is toward cure. Most of the cases referred to him are 
progressive and tuberculous. 

The lymphatic enlargement of beginning Hodgkin's disease is rapidly 
progressive, the tumor shortly reaching a size beyond that encountered 
in inflammatory cases while still preserving its normal consistency-. 

Chronic adenitis in the inguinal region, usually secondary to urethral 
inflammation, occasionally maintained by a fissure or other anal lesion, 
or by repeated slight trauma of the feet, or following excessive coitus 
without genital lesion or assignable cause, is distinguished from syphilitic 
bubo by the absence of the primary sore of the latter disease and its 
different evolutions; from tuberculous adenitis by discovery of a non- 
tuberculous source of infection or by the failure of the glands to undergo 
the typical tuberculous evolution. 

Syphilitic Adenitis. — Syphilitic adenitis is a customary early manifes- 
tation of syphilitic infection, involving, first, the glands anatomically 
connected with the seat of primary lesion, later to some extent all the lym- 
phatic glands of the body. The syphilitic buboes, symptomatic of chan- 
cre, are characterized by their multiplicity and painlessness, the individ- 
ual glands rarely attaining a size greater than the last joint of the thumb 
and remaining freely movable and non-adherent to each other beneath 
the skin. The glands in the upper postcervical regions and those placed 
in front of the internal condyle of the humerus are the ones whose en- 
largement is considered particularly characteristic of the developing 
secondary lesions. Suppurative adenitis is occasionally observed as 
the result of mixed infection. 

A general glandular involvement with moderate fever and the muscle 
pains of toxemia occurs as the result of infections other than syphilis. 
This is seen in la grippe epidemics. The distinction from syphilis is 
based on the absence of a primary lesion. 

Tertiary syphilis is exceptionally characterized by multiple, indurated. 



THE LYMPH VESSELS AND GLANDS 105 

painless glandular swellings, particularly in the neck, axilla, the elbow, 
and the groin. 

Gumma (extremely rare) occasionally develops in the glands of the 
groin and neck. The progress is slow (months); softening and ulcera- 
tion occur before the glands reach the size of a hen's egg. 

The diagno^s in the infiltration period cannot be made from malignant 
growth, except by a consideration of the history and the finding of more 
characteristic lesions or their scars. 

There is a phagedenic form of ulceration secondary to syphilitic lymph- 
adenitis observed in the groin. The skin lesion, incident to perforation 
of the abscess, slowly (months) extends, inducing widespread destruction 
of both the superficial and the deep tissues. 

Tuberculous Adenitis. — ^Tuberculous adenitis, commonest in ill-nourished 
girls of the second decade but observed at any age, strongly predisposed 
to by heredity and affecting by preference chronically inflamed glands, 
has for its seats of predilection the neck, the groin, and the axilla. In the 
neck the submaxillary and the deep cervical nodes commonly are first 
involved. Tuberculosis of the axillary and inguinal nodes is less fre- 
quent. 

In its early stages tuberculous adenitis cannot be distinguished from 
inflammatory hyperplasia of other origin. There is a painless induration 
and enlargement of one or all of the gland group which may persist for 
months or years without change other than gradual growth and pro- 
gressive involvement of glands lying nearer the trunk. As a rule, a gland 
group, sometimes the entire chain, exhibits the symptoms of a chronic 
periadenitis, i. e., the surrounding tissues become infiltrated and form 
part of the tumor mass, and individual glands soften and discharge 
through the skin, leaving ragged, undermined openings, from which 
there is a continuous running of thin, curdy pus. 

The diagnosis is suggested by the age incidence, the chronicity, the 
absence of pain or marked tenderness, the tendency to extend toward the 
trunk glands, and the persistence after the cure of an infecting focus 
which might account for chronic inflammatory hyperplasia. The diag- 
nosis should be strengthened by tuberculin injection, and, if needful, 
should be confirmed or disproved by removal of the gland before the 
period of suppuration. 

Exceptionally tuberculous adenitis presents almost the identical feat- 
ures of Hodgkin's disease. 

Hodgkin's Disease.— Hodgkin's disease, occurring usually in men, is 
characterized by the slow or rapid growth of lymphatic glands, at first 
distinct from each other, finally merging to form huge masses. There is 
usually an associated intermittent fever. The blood shows no changes 
excepting diminished hemoglobin and eosinophilia. 

This affection usually begins as a soft, painless enlargement of one or 
two of the cervical glands, or of the axillary or inguinal group. At this 
stage the preservation of normal elasticity and consistency, the absence 
of an exciting cause, and particularly rapid growth, without exhibiting any 
tendency toward periadenitis might suggest a diagnosis. Similar growths 



106 THE LYMPH VESSELS AND GLANDS 

in other regions shortly make the nature of the affection plain. Removal 
for microscopic examination shows usually the structure of the normal 
gland or one exhibiting a slight degree of inflammatory hyperplasia. 

Lymphatic Leukemia. — ^Lymphatic leukemia is characterized by similar 
enlargements associated with tumefaction of the spleen, the liver and 
thymus, and bone-marrow changes. The diagnosis is based on blood 
examination, which shows marked leukocytosis, the lymphocytes being 
relatively and absolutely enormously increased in number. The myelo- 
genous form of anemia is characterized by leukocytosis with many 
myelocytes. 

Lymphosarcoma. — ^Lymphosarcoma as a primary affection usually in- 
volves a group of glands, presenting precisely the picture characteristic 
of Hodgkin^s disease with the exception of the blood changes. The growth 
is rapid, and quicldy invades the surrounding tissues. The diagnosis 
should be made by the prompt removal of the soft, rapidly growing, 
apparently causeless gland or group of glands. 



CHAPTEE IX. 

THE MUSCLES, TEXDOXS, AXD BURS.E. 
THE MUSCLES. 

Traumatisms. — Contusion. — Contusion of the muscle is characterized 
by a condition of partial palsy, deep pain, local tenderness to palpation 
and on movement, swelling, and late (days) ecchymosis. 

If there has been extensive blood effusion, which always implies 
muscular rupture, there will be formed rapidly a fluctuating tumor, 
which later becomes indurated and may ultimately exhibit bony hard- 
ness. 

Unless the nerves be involved, atrophy and contracture are not likely 
to occur. 

Rupture. — Rupture of muscles is caused by violent contraction or the 
direct application of force when they are in a condition of contraction. 
Predisposing factors are muscular degeneration such as follows pro- 
longed fevers and overuse. It is common in athletes out of training. 

In the order of frequency the rectus abdominis, the adductors of the 
thigh, the pectoralis major, the deltoid, the midportion of the quadriceps 
extensor, the muscles of the back, the muscles of the calf, and the flexor 
muscles of the legs and arms are the ones involved. 

The rupture may be fibrillary, partial, or complete. 

Fibrillary rupture is characterized by sudden severe pain, disability, 
and usually tenderness on deep pressure. It is the usual cause of affec- 
tions called sprained back, sprained neck, sprained shoulder. The pain 
on motion and tenderness may last for weeks in the absence of immobili- 
zation. 

Complete ruptures usually located at or near the musculotendinous 
juncture, and characterized by a feeling of something having given way, 
are accompanied by sudden pain, usually extremely severe; immediate 
disability, not only of the affected muscle, but of the whole muscle group ; 
tenderness; gap in continuity at the seat of break, vfith a hard lobular 
swelling at either end of the breach, the proximal one most pronounced 
and increased in size and hardness by efforts at contracture; often the 
rapid formation of a large blood tumor; and late ecchymosis. 

A central partial rupture exhibits the symptoms of the complete rup- 
ture, the pain being even more severe. In place of a gap in continuity, 
there is formed a rounded or oval tumor which becomes denser and more 
pronounced and moves upward during contraction and can be partially 
reduced when the muscle is relaxed. This at first may be obscured by 
tenderness and blood effusion. 



108 THE MUSCLES, TENDONS, AND BURS^ 

Partial rupture may recover in a few weeks. Sometimes it becomes 
the seat of osteoma. Very exceptionally atrophy results, due to rupture 
of the nerve. One or both fragments may undergo this change. 

Hernia. — Hernia of the muscle (extremely rare) is a gradual develop- 
ment, due to a yielding of the fibrous sheath. There is formed a small 
oval tumor without subjective symptoms. It is soft and prominent when 
the muscle is relaxed. When the muscle is forcibly contracted it becomes 
hard with the rest of the muscle, not more so, and either partially or 
completely reduced. There is but slight interference with function. 

Most cases reported have been those of muscular rupture. From 
rupture it may be distinguished by its slow and painless development and 
its different behavior on forced contraction ; from tumor, by the fact that 
the latter does not change in density or volume incident to contraction 
either voluntary or forced. 

Myositis. — Myositis may be traumatic, toxic, or infectious; acute or 
chronic. It is exceptionally suppurative. 

Infection may be due to extension of inflammation from the surround- 
ing parts, or may occur as a local expression of systemic poisoning, in the 
course of acute infections or after them. Myositis is characterized by 
extreme pain greatly aggravated by motion, tenderness, swelling, indura- 
tion and contracture producing a fixed position. 

Traumatic Myositis. — Traumatic myositis, representing the reaction 
from contusion, sprain, or overuse, is typically instanced by the affec- 
tion of the extensors of the leg called by football men ^'Charley horse," to 
a less degree by the stiffness and soreness of any group of muscles subject 
to unaccustomed, violent, or prolonged use. It predisposes to muscular 
rupture. 

Toxic and Infectious Myositis. — ^Toxic and infectious myositis, usually 
rheumatic, is common in the muscles of the shoulder, back (lumbago), and 
neck (sternomastoid, trapezius, extensors). It is always a symptom of 
systemic poisoning, often of focal origin (appendix, tonsils, teeth, sinuses 
of the head). 

Exceptionally there is multiple involvement, the skin overlying the 
affected muscle being reddened and edematous, the muscle below swollen, 
tender, hard (sometimes soft), and painful on movement. 

Suppurative Myositis. — Suppurative myositis may be expressed in the 
form of localized abscess or diffuse phlegmon. 

A localized abscess reaches the surface slowly. The seat of suppura- 
tion is characterized by an almost bony hardness, followed by softening, 
taking place in days or weeks. 

Early diagnosis is based on the deep seat of the inflammation, its 
acute onset, its limitation to the muscle affected, fixed position due to 
contracture, and the constitutional symptoms of retained pus. 

Diffuse Phlegmonous Myositis. — Diffuse phlegmonous myositis occurs 
in those of depressed vitality subject to prolonged fatigue. It is at times 
a sequel to trauma. It begins with characteristic violent septic symp- 
toms and severe pains, often supposed to be rheumatoid. Nicaise calls 
attention to the frequency of head symptoms, particularly pain and active 



THE MUSCLES 109 

delirium and violent agitation. Constitutional symptoms may entirely 
overshadow the local lesion. Tenderness and pain in the muscle, with 
contracture, are accompanied by an edematous thickening not so clearly 
outlined as in the case of non-suppurative myositis. The course is 
extremely acute, much like that of osteomyelitis. 

Chronic Myositis. — Chronic myositis may follow an acute attack. In 
the absence of other demonstrable cause it is called rheumatic. It is 
characterized by induration and slow contracture. 

Ossifying Myositis. — Ossifying myositis may occur about the seat of an 
old fracture, may be an extension from osteoarthritis, or may be due to 
muscular trauma, particularly that which is moderate in severity and 
frequently repeated. Partial muscular rupture is particularly a predis- 
posing factor. 

Its commonest manifestation, so-called "rider's osteoma,'^ is placed 
near the pubic insertion of the adductors. There may be multiple 
foci of ossification in the muscle. These tumors have also been observed 
in the deltoid and brachialis anticus, and occasion little distress aside 
from mechanical interference with function. 

Progressive ossifying myositis is usually observed in the male; some- 
times the newly born; as a rule, before the fifteenth year. There is a 
preliminary swelling. The dorsal muscles of the spinal column, particu- 
larly those in the cervical region, are first involved. The affection is 
irregularly progressive, characterized by disseminated areas of swelling 
in the muscle, by tenderness and often skin edema, and fixed position. 
The swellings become hard and finally bony. 

Diagnosis is based on the generalization of the affection. 

Tuberculosis of the Muscles. — Tuberculosis of the muscles is usually 
secondary to neighboring bone or surface affection. In its primary 
form (rare) it may appear as a nodule (tuberculoma) or cold abscess or 
general infiltration. 

Tuberculoma cannot be distinguished in its early stages from gumma 
or neoplasm. If gumma can be excluded with reasonable certainty the 
diagnosis should be made by excision. 

Cold abscess of the muscle, exceptionally due to softened primary 
muscle tuberculoma, usually to an extension of tuberculous infiltration 
from bones or joints, is characterized by tumor and fluctuation preceded 
by the symptoms of chronic myositis (contracture). Acute inflammatory 
symptoms are absent until the skin is about to break. 

General infiltration occurs secondary to bone and joint tuberculosis 
and is followed by softening and abscess formation. 

Syphilis of Muscles. — Myosalgia, or acute muscular pain, is a common 
affection of early syphilis; indeed, it is one of diagnostic value, especially 
as it occurs about the shoulders and back of the neck. In the case of the 
sternomastoid muscle it may produce torticollis. 

The muscles are tender, both on movement and palpation. The 
affection has been called syphilitic rheumatism. 

Syphilitic myositis attended by contracture, particularly common in 
the biceps, also observed in the sternomastoid, the trapezius, the biceps 



no THE MUSCLES, TENDONS, AND BURS^ 

femoris, and other muscles, occurs in the first year of the disease as an 
expression of the secondary period. It is characterized, first, by mus- 
cular stiffness, swelling, and hardness, followed, in the case of the 
biceps, by fixed flexion of the forearm. Even in the absence of syphilitic 
history or other signs of the disease such a contracture not incident to 
trauma or nerve lesion can be regarded as characteristic. 

Tertiary syphilitic myositis is characterized by swelling and induration 
which may be diffuse or circumscribed. The diffuse form exhibits the 
symptoms of the secondary involvement, except that the onset is more 
insidious, the course slower, the swelling greater, the contraction more 
marked. Pain and tenderness may be severe or absent. The muscular 
structure entirely degenerates and is replaced by fibrous tissue. The 
sternomastoid, the rectal sphincter, the biceps, pectoralis major, the 
deltoid, the common extensors of the fingers, the trapezius, and the calf 
muscles are those of predilection. The early diagnosis is of major 
importance, since treatment is futile after muscular degeneration has 
become complete. 

Gumma of the muscle may begin with subacute inflammatory phe- 
nomena or entirely in the absence of these, forming at first an ill-defined, 
slow-growing (weeks) infiltration, later a rounded or elongated tumor 
in the muscle substance, usually near the region where the latter merges 
into the tendon. Such tumors occasionally involve at the same time the 
same muscle on the two sides of the body. They may undergo absorp- 
tion and sclerosis. They usually soften and break down, forming typical 
gummatous ulcers. 

Neoplasms. — Neoplasms of the muscles are usually benign. 

Angioma and lymphangioma, usually congenital, are suggested by their 
softness, obscure outlines, and alterations in sizes, incident to dependent 
and elevated positions of the parts in which they are placed ; often they 
are associated with cutaneous and subcutaneous tumors of a similar 
nature. 

Lipoma, encapsulated and of slow growth, may be inferred from its 
lobulation and softness. 

Enchondroma is characterized by its density. 

Sarcoma begins precisely as do the benign tumors, gumma and tuber- 
culous infiltration. It is distinguished from the latter clinically only in 
its late development, growing to a much larger size. The diagnosis by 
any form of examination is absolutely impossible at the time it is ser- 
viceable. It should be made, if gumma be excluded, by the prompt 
excision of any apparently causeless, rapidly (weeks) growing tumor 
placed in the muscle. 

Echinococcus Cyst. — Echinococcus cyst, commonest in women, is char- 
acterized by the slow growth (years) of a hard rounded muscle tumor 
which rarely reaches large size. Occasionally this tumor gives the 
so-called hydatid fremitus. 

Diagnosis is impossible without exploration, since the hydatid cyst 
may exactly simulate gumma, tuberculoma, hematoma, indeed, any of the 
muscle tumors. 



THE MUSCLES 111 

Muscular Contracture. — ^This term, implying persistent shortening as 
contrasted with contraction, which indicates the intermittent physiological 
process, may be reflex, postural, myositic, of central nerve origin. 

Reflex contracture is an early and nearly constant symptom of arthritis 
and peritonitis, involving the muscles whose action is most protective. 

Myositis in any of its forms, if persistent, is followed by contracture 
due to the formation of fibrous tissue. 

Postural contractures are such as are observed after long splinting or 
fixed position; or as occur sequent to failure to provide against the effects 
of gravity and unopposed force after peripheral palsies. 

Ischemic contracture palsy due to pressure which cuts off blood supply 
is particularly noted in the forearm after tight bandaging; in all the 
extremities after the Esmarch tube. It may follow wounds or ligature 
of larger vessels. The degeneration affects muscular fibers, the nerves 
themselves remaining intact. It is characterized by contracture, loss 
of power, and atrophy. 

The severe forms are incurable. 

Atrophy. — Atrophy of muscles is due to non-use, long-continued con- 
tracture, as from inflammation and fixation of joints, persistent extension 
and peripheral nerve lesions. Atrophy of joint inflammation is in part 
reflex. It is particularly marked in the deltoid and in the extensors of 
the thigh. 

Paralysis. — Paralysis of muscles is due to injury or disease of central 
or peripheral nervous system or to muscular degeneration. 

Postanesthetic Paralysis. — Postanesthetic paralysis may be central, 
hysterical, reflex, or peripheral. It is usually peripheral, and follows 
prolonged Trendelenburg position with the arms hanging over the head. 
Thus is pinched the brachial plexus against the transverse vertebral 
processes, between clavicle and first rib; or possibly against the head of 
the humerus. 

The upper cords are most injured, as expressed by paralysis of the 
deltoid, biceps, brachialis anticus, and long and short supinators. All 
of the muscles of the arm may be involved. 

The arm resting against the edge of a table may compress the musculo- 
spiral nerve, causing wrist-drop, or the peroneal muscles may be paralyzed 
by pressure on the external popliteal. 

The diagnosis is based on the finding of a paralysis not present before 
operation and by the rapid and progressive development of the reactions 
of degeneration in severe cases. 

Crutch palsy is usually expressed in the muscles supplied by the 
musculospiral nerve; those innervated by the median or ulnar may be 
involved. 

Obstetric or birth palsy following difficult labor usually involves the 
brachial plexus. It may affect the mother by pressure of the head 
upon the sciatic or obturator nerve, causing pain, contracture, and palsy. 

In the child it is commonly manifested by facial palsy from forceps 
pressure; or brachial plexus palsy usually of the superior root type, i. e., 
deltoid, biceps, brachialis anticus, infraspinatus, and supinator longus. 



112 THE MUSCLES, TENDONS, AND BURSJE 

Reflex palsies, characterized by exaggerated reflex, moderate, but 
persistent atrophy, and diminution in electrical excitability, but not the 
reactions of degeneration, are such as are observed following joint trauma. 



THE TENDONS. 

Trauma of the Tendons.— Wounds. — Wounds of the tendons, usually 
obvious on inspection, are characterized by complete loss of that 
motion on which their integrity is dependent. When the tendon is 
completely divided, often, but not always, there can be felt a loss of con- 
tinuity, and the divided ends can be palpated, the proximal one moving 
with contraction of its muscle and often retracted from the wound. 

Rupture. — Rupture of the tendons is characterized by sudden pain, the 
loss of motion which was dependent upon the integrity of the tendon, 
and usually an appreciable gap in continuity, filled in by blood which can 
be pushed aside, thus allowing the two extremities of the tendon to be felt. 
The distinction from muscular rupture is made by the position of the 
break; from tearing away of the tendinous insertion of the bone; 
sometimes, but rarely, by bony crepitus or palpation of the bony 
fragment. 

Luxation. — Luxation of tendons in the absence of complicating 
fracture is rare. It usually affects the tendon of the peroneus longus. 
What has often been called luxation of the long head of the biceps is 
usually a subacromial bursitis. 

Tendon luxation is accompanied by pain, the sensation of something 
having given way, by impaired function, and local tenderness. The dis- 
placed tendon can be felt and reduced. 

Inflammation of the Tendon.— Peritendinous Cellulitis. — Peritendin- 
ous cellulitis may be traumatic or infective, and involves the cellular 
tissue immediately surrounding tendons not provided with an investing 
synovial sheath. It is common after overuse, and in the foot often follows 
the wearing of ill-fitting shoes, forming a tender, puffy, edematous swelling 
on either side of the tendo Achillis, which gradually fades into the sur- 
rounding healthy tissues. 

The diagnosis of this condition is based on the position of the swelling. 
If the inflammation becomes suppurative, tendon sloughing is likely to 
result. 

It is distinguished from inflammation of the bursa by the fact that the 
outlines of the latter are rounded and distinct. 

Syphilis of the tendons may appear as infiltrations or small gummatous 
nodules. 

Fibroma and fibrosarcoma are rare tumors of tendons. 

A fibrous nodulation, probably traumatic, of the flexor of a finger 
causes a peculiar locking in flexion and extension, followed by a sudden 
giving way, called trigger finger. 

Tenosynovitis. — ^The inflammations of the synovial sheaths of tendons 
correspond in etiology, and to some extent in symptoms, with inflamma- 
tions of other synovial sacs. 



THE TENDONS 113 

The inflammation may be traumatic, toxic or infectious, acute or 
chronic, serous, plastic or suppurative. 

Acute tenosynovitis is usually due to overuse or sprain. In its mildest 
form it represents simply a hyperemia and a slight hypersecretion, and is 
termed crepitant tenosynovitis from the fine crackling sensation given 
when the tendon slips in its synovial sheath as the result of muscular 
contraction. 

Tenderness, pain on motion, and crepitation, elicited by grasping the 
part and directing the patient to make movements which require contrac- 
tion of the muscle of the involved tendon, are the characteristic symptoms. 
The swelling is slight. There may be a rosy edema of the overlying skin. 
The tendons commonly involved are those of the forearm, wrist, hand, 
and ankle. 

If the trauma be severe, there is distinct effusion not only within the 
tendon sheath, but in the surrounding tissue, forming a cylindrical 
swelling in the course of the tendon, which is tender to pressure and on 
motion. This effusion may undergo organization fixing the tendon. 

Plastic and serous tenosynovitis are occasionally expressions of con- 
stitutional toxemia or infections such as rheumatism, la grippe, typhoid, 
pneumonia, and the exanthemata. They are usually due to gonorrhea. 
The effusion is fibrinous rather than serous, and moderate in quantity. 
Exceptionally it is abundant and undergoes organization, limiting motion. 
This is particularly likely to be the case when the inflammation of the 
tendon is associated with a gonorrheal arthritis. 

Suppurative synovitis is usually due to direct infection through a 
wound or to extension from surrounding soft parts. It is common in 
the tendons of the finger and hand secondary to panaris or palmar 
abscess, and is characterized by a tender, edematous swelling extending 
along the tendinous sheaths, with the local and systemic symptoms of 
acute extending suppuration. 

Suppurative tenosynovitis is often followed by extensive sloughing of 
tendon, or, if this is avoided, by firm adhesion of the tendon to its sheath 
or to the surrounding soft parts. 

Chronic tenosynovitis may be traumatic, toxic or infectious. It is 
usually tuberculous. 

Chronic tenosynovitis due to repeated slight trauma, or to overuse, 
appears as a serous effusion, forming a soft, fluctuating, painless tumor 
in the course of the tendon sheath. This is rare. 

Tuberculous tenosynovitis appears in the serous or fungous form. 

In the serous form the synovial sheath is greatly thickened, distended 
by a thin fluid, and contains few or many white bodies varying greatly 
in size, looking like grains of half-boiled rice. The enclosed tendon may 
be quite intact or may be fibrillated and torn across. 

This may be the sole demonstrable manifestation of tuberculosis. It 
often follows slight traiuna, and is usually found in the common sheath 
of the flexors of the fingers. Occasionally it involves the sheath of the 
extensors of the hand or of the foot. 

It is characterized by slow growth, with periods of acceleration incident 
8 



114 THE MUSCLES, TENDONS, AND BURS^ 

to trauma, and in the hand by the formation of a characteristic tumor, 
non-sensitive, fluctuating, which projects in the palm and the wrist and 
is divided into two portions by the annular ligament. There is usually 
a crepitation which is distinct, and has been compared to the rubbing of 
a chain. When the solid bodies are few or absent this friction sound 
cannot be elicited. 

The muscles of the tendons involved are contractured and ultimately 
atrophy. The fingers are moderately flexed and cannot be extended. 
When the sheath of the extensor tendons of the hand is involved a globular 
swelling forms on the back of the wrist. 

The affection is slowly progressive (years). Untreated it ultimately 
ulcerates and becomes converted into the fungous form. 

Fungous synovitis is usually secondary to tuberculous involvement of 
bones or joints. In its primitive form it may develop as an expression 
of general tuberculosis or as an isolated lesion. The synovial lining and 
often the tendons themselves are invaded by a mass of lowly vitalized 
gelatinous granulation tissue. 

It occurs, as a rule, in the young, and is most frequent in women. The 
predisposing factors are slight trauma or repeated irritation, as from 
excessive use of certain tendons. It occurs particularly in the sheaths 
of the common flexors of the fingers or those of the thumb. It is also 
observed about the ankle. 

The fungosity begins in the cul-de-sac at either end of the tendinous 
investment, and finally involves the whole sheath. 

The onset is gradual, being attended by slight soft swelling and limita- 
tion of motion. The further progress is evidenced by a slow (months, 
years) increase in swelling, occupying the position of the tendon sheath. 
In the palm the swelling is bilobed by the annular ligament. In the early 
stages the swelling can be slightly displaced laterally and also moves 
with the tendon, showing close connection between the two. The tendons 
at first become fixed, limiting motion ; later they soften and break. This 
does not alter the fixed position of the parts, since the distal stump of the 
tendon remains adherent to its sheaths. Ultimately (years) softening 
occurs with tuberculous ulceration. Neighboring joints may be involved. 

This affection may be distinguished from syphilis by its wider diffusion, 
its slower course, and in the case of syphilitic lesion associated specific 
lesions and the therapeutic test; from lipoma, by the slower course of 
the tumor, absence of tendon fixation and muscular atrophy, and free 
mobility of the part; from sarcoma, by the rapid growth of the latter, and 
by operation; from tuberculous arthritis, the late stage of which it generally 
complicates, by the location of the swelling and the rc-ray. After sinus 
formation the depth and direction of these and the presence or absence 
of dead bone on probing will suggest the diagnosis of the seat of the 
affection. 

Syphilitic tenosynovitis may take the serous or gummatous form, the 
former during the secondary period. It affects by predilection the 
extensors of the hand and foot. It is insidious in onset, exceptionally 
inflammatory, may be symmetrical, and causes but trifling disability. 



THE BURS^ 115 

Gummatous tenosynovitis (rare) forms an induration which grows to 
an ill-defined, hard, rounded tumor in the course of weeks or months, 
usually softening before reaching the size of the end of the thumb and 
discharging through a central ulceration. 

Tumors of the Tendon Sheaths. — ^Tumors of the synovial sheath are 
the lipoma, fibroma, and sarcoma. 

Lipoma. — Lipoma has been observed in the extensors of the hand and in 
the sheath of the flexors beneath the palm. The soft tumor simulates 
tuberculous tenosynovitis; it does not, however, fix the fingers in flexion 
with muscular atrophy. The diagnosis must be made by incision. 

Fibroma. — Fibroma (rare), usually observed in the tendon sheaths of the 
fingers, forms small hard tumors of slow growth. In their first develop- 
ment these tumors should be distinguished from sarcoma by excision and 
by microscopic examination. 

Fibrosarcoma. — Fibrosarcoma is usually observed in the flexor tendon 
sheaths of the fingers and hand. It remains small and quiescent for 
years and then begins a rapid growth. Until this period of growth it 
exhibits the symptoms of fibroma, nor can the diagnosis be made except 
by excision and microscopic examination. 



THE BURS.ffi. 

The bursse are connective-tissue sacs with an endothelial lining. They 
are antifriction devices which secrete a synovial fluid. In the positions 
where they are customarily encountered they are not developed until 
their presence is required by muscular activity, hence children are wanting 
in many of them. They may develop in regions where they are not 
customarily found as the result of pressure and friction, and are then 
termed accidental, or adventitious. 

Bursitis. — Bursitis may be traumatic, secondary to inflammation of 
surrounding parts, or a local expression of systemic poisoning, as from 
the acute and chronic infectious diseases (gonorrhea, rheumatism, 
exanthemata, etc.). 

Acute Bursitis. — Acute bursitis is characterized by pain increased by 
motion, tenderness, often crepitation at first, later fluctuation in the 
region of the bursae. If the exudate is fibrinous or serous, there will be 
no other symptoms. If the affection is suppurative (secondary to infecting 
wound or peribursal suppuration), the local and general symptoms of 
acute suppurative infection will be present; at first localized to the bursa 
and its immediate environment, later characterized by a diffuse phleg- 
monous infiltration of the soft parts, or even of the joint, causing acute 
suppurative arthritis. The distinct localization, clear outlines, and rapid 
progression of the inflammatory tumor are in the early stages diagnostic. 
Even when suppuration takes place the general inflammatory edema 
will be found to focus in the region of the bursa. It is only when the 
inflammation has been allowed to run on to diffuse phlegmon that the 
complications obscure the original lesion. 



116 THE MUSCLES, TENDONS, AND BURSM 

Chronic Bursitis. — Chronic bursitis is characterized by the gradual 
formation of a tumor, usually fluctuating, exceptionally translucent, and, 
when placed beneath a tendon, becoming tense or flaccid in accordance 
with the position of the joint. It is usually of medium size, not larger 
than an average orange, though it may become huge. It is sharply out- 
lined and corresponds in position with that of a normal bursa or in 
history and mechanics of development with that of an adventitious one. 
Often crepitation and at times the rice-like bodies with which these bursse 
are frequently filled can be felt. 

The fibrous hemorrhagic hygromata so exactly simulate tumor that 
the diagnosis can be made only by operation, though it may be suspected 
from the anatomical position of the growth, often subject to transitory 
attacks of acute inflammation. 

Acute infection of a chronically inflamed bursa, often following 
trauma, usually leaves a fistula which refuses to close. The nature of 
this fistulous tract is determined by probing and exploratory operation. 
The x-rays also are useful, since they will demonstrate the absence of a 
bone lesion. 

The sac wall may be greatly thickened or even cartilaginous in places 
and closely adherent to the surrounding parts, or even surrounded 
by a dense fatty deposit. The inner surface may be clean, may exhibit 
vegetating outgrowths, or in gouty patients calcareous concretions. From 
organization of repeated small hemorrhages of the sac the wall may 
become so thick as to suggest solid tumor, the fluid contents of which are 
entirely obscured by the rigid sac. Or the contents may be solid or semi- 
solid, appearing in the form of partially organized fibrin or granular 
debris. 

The bursse commonly involved in chronic inflammation are the olec- 
ranal, supra-acromial, subacromial or subdeltoidean, subiliac, trochan- 
teric, prepatellar, subpatellar, pretibial, semimembranosus, popliteal, and 
that of the tendo Achillis. 

Tuberculous Bursitis. — Tuberculous bursitis usually secondary to infec- 
tion of the neighboring joints, sometimes primary, is especially observed 
in the bursse about the knee, shoulder, elbow, and hip-joint. It is char- 
acterized by tuberculous infiltration of the bursal wall, a serous effusion, 
ultimately caseous degeneration and the formation of a cold abscess. 
In its comparatively early manifestation the affection may assume either 
the serous or the fungating form. 

Tuberculous bursitis is characterized by tumor in the position occu- 
pied by a constant or an adventitious bursa. This tumor offers the 
characteristics of other forms of bursal effusion. A single suggestive 
feature is its causelessness. The diagnosis may be made by excision 
and microscopic examination, or aspiration of the bursal contents and 
injection into susceptible animals. The ultimate history of a tubercu- 
lous hygroma is fistulization. 

Syphilitic Bursitis. — Secondary syphilis may cause a serous effusion in 
the bursse, with inflammatory symptoms either slight or wanting. 

Gummata are fairly common, particularly in the prepatellar and the 



THE BURS^ 117 

pretibial bursse and that of the olecranon. Traumatism is a predisposing 
factor. The affection is sometimes symmetrical. 

Both the serous effusion and gummata are characterized by the absence 
of subjective symptoms and promptly yield to specific treatment. The 
gummatous affections usually soften and ulcerate, forming the character- 
istic punched-out ulcer. The distinction from tuberculosis in the late 
ulcerating cases must be based upon the history and the associated 
lesions. 

Tumors of the Bursa. — Sarcoma is the commonest bursal tumor. 

Myxoma, enchondroma, smd fibrochondroma, all tumors of slow growth, 
have been observed. The neighboring joints are not involved and the 
tumor is usually movable over the bone. The diagnosis should be 
suggested by the existence of a rapidly growing bursal tumor and must 
be confirmed by prompt excision. 



CHAPTER X. 

THE BONES AND JOINTS. 
THE BONES. 

Traumatism. — The bones may be bruised or broken. 

Contusion. — Contusion is characterized by pain, usually severe, deeper 
placed and more persistent than that of bruising the soft parts, by ex- 
quisite tenderness on deep pressure, and, if the bruised bone is super- 
ficially placed, by palpable swelling, not movable over the underlying 
bone. There may shortly follow this injury a soft subperiosteal hema- 
toma. 

The osteitis resulting from the contusion usually is circumscribed and 
undergoes prompt and complete resolution. It may be persistent and 
be followed by distortion (coxa vara) or by bony overgrowth. Sup- 
purative or tuberculous osteitis is an occasional sequel. 

Fracture. — Commonest in males except at the extremes of life, may 
result from either direct or indirect force or muscular action. 

Direct force breaks the bone at the seat of application; indirect force, 
in the case of the long bones, usually toward their extremities. 

The fracture may be simple, the line or lines of bone-break not com- 
municating with a skin wound, or compound, there being in this case 
such communication. The break may be incomplete (green-stick 
fracture, fissured fracture) or complete. 

A multiple fracture is one in which a bone is broken into more than two 
fragments. A comminuted fracture is multiple, with the lines of cleavage 
intercommunicating. 

The direction of the break is usually oblique ; it may be transverse 
(direct violence) or spiral. The latter frequently in the bones of the leg 
and in the femur and humerus. 

The deformity of the fracture may be angular, transverse, rotary, or 
longitudinal. Often it is a combination of these, the displacement being 
produced by the vulnerating force, muscular contraction, and the weight 
of the part. 

iVn impacted fracture implies the driving of one fragment into another 
so firmly that preternatural mobility cannot be elicited. 

Fracture from muscular contraction is usually in the form of a tearing 
off of a shell of bone at the point of tendon insertion. This is a common 
complication of luxation. The ribs, the clavicle, the humerus, any of 
the long bones may be broken through their long axis by muscular 
action alone. 

Birth fractures are comparatively common following instrumental 



THE BONES 119 

or manual delivery, or even in the absence of these. The bones of the 
skull are those which suffer most. The clavicle, femur, and humerus 
are also frequently involved. 

Spontaneous fracture, by which is meant the break of a bone from 
trifling force, should always suggest either a local or a systemic predis- 
posing condition. 

Among the predisposing conditions are osteomyelitis, suppurative, 
tuberculous, or syphilitic; infiltrating or eroding tumors; rickets; osteo- 
malacia; senility; pregnancy; locomotor ataxia; psychoses; paralysis, and 
disuse atrophy. The diagnosis is often not made until visible deformity 
calls attention to the lesion, since those spontaneous fractures have few 
subjective symptoms and often occur in patients whose major malady 
inhibits function. There is at times an enormous outgrowth of callus 
attending union which is usually slow and often never takes place. 

Aside from the causes predisposing to fracture already given there is 
a bone fragility of unknown origin unassociated with other lesions, some- 
times congenital, often persisting through life and characterized by 
many fractures which heal kindly. This is called fragilitas ossium. 

The diagnosis of fracture is based on the presence of one or all of its 
cardinal symptoms: (1) Abnormal mobility; (2) deformity; (3) crepitus. 

The abnormal mobility is detected by direct palpation at the seat of 
break supplemented in the case of the long bones by extension, and, 
where this is applicable, attempts at angulation. It is absent in green- 
stick and fissured fractures, and in those which are impacted. 

Deformity, often obvious on inspection and palpation, is usually cor- 
roborated by mensuration and the x-tsljs. It is absent in fissured 
fractures. It may be present only when produced by manipulation in 
subperiosteal and epiphyseal fractures and in breaks of bone naturally 
splinted by either another bone or muscle, as in the case of the fibula, ribs, 
or scapula. 

Crepitus is detected by rubbing the broken ends of the bone together. 
This is accomplished by direct manipulation or by pulling, angling, 
and rotatory movements of the distal fragment, the proximal one being 
fixed. Crepitus can be distinctly felt as a grating, and can be heard by 
the naked ear or by means of a stethoscope. It is absent in incomplete 
and impacted fractures and in those the broken surfaces of which cannot 
be brought into apposition either because of wide separation or inter- 
position of soft parts. 

In addition to these cardinal fracture symptoms there are those of all 
severe trauma, i. e., pain, disability, swelling, and discoloration, the latter 
coming on late (days). 

Pain and tenderness are felt at the seat of fracture, and both are per- 
sistent even in the absence of deformity. Disability is usually pro- 
nounced. 

Swelling and late discoloration not due to direct trauma are extremely 
suggestive symptoms. 

Sugar, indican, and fat are commonly found in the urine after fracture 
and are of some slight diagnostic value. 



120 THE BONES AND JOINTS 

The fever reaction, rarely over 100°, for one to three days, is that 
common to trauma. 

The examination for fracture cannot be considered complete until the 
presence or absence of lesions of important nerves and bloodvessels lying 
near the seat of injury has been determined. 

Within twenty-four hours there very commonly develop about the 
seat of fracture, particularly when the tibia, humerus, or both bones of 
the forearm are broken, large vesicles filled with blood-stained serum. 
These blisters, often attributed to irritating dressing, are quite indepen- 
dent of the latter. 

Fractures which lie partly or wholly within the joints in addition to 
the symptoms common to all fractures, are characterized by a rapid 
distention of the articular cavity, due to free bleeding and later serous 
effusion. Because of the rapid swelling and marked tenderness attend- 
ing these joint fractures, the examination is rarely satisfactorily diag- 
nostic unless it be made by the a;-rays or, in the absence of these, by the 
aid of an anesthetic. 

Delayed union may be due to local or systemic cause. It is character- 
ized by preternatural mobility persisting at the seat of fracture after the 
period (four weeks) when consolidation should have taken place. It is 
usually associated with tenderness on motion, marked disability, and hard 
swelling due to hyperabundant callus. Exceptionally callus formation 
is totally wanting. The local conditions usually at fault are imperfect 
apposition, inadequate mobilization, the interposition of soft parts; 
exceptionally, inflammatory lesions or malignant infiltration. 

Ununited Fracture. — This condition represents a persistence of delayed 
iniion beyond the period when there is a reasonable expectation of union 
without surgical intervention (twelve weeks). Its causes and symptoms 
are those of delayed union. 

Diagnosis is based on the detection of preternatural mobility; this is 
usually, but not always, associated with pain greatly aggravated by 
attempts at function. Unnatural mobility is at times difficult to elicit. 
The :r-rays may be needed for diagnosis. 

Vicious union due to improper apposition or inadequate retention is 
usually manifest on inspection. At times it is dependent on callus for- 
mation which by its bulk interferes mechanically with movement, exerts 
a crippling pressure on muscles, tendons, nerves, and bloodvessels, or 
binds the bones which normally move upon each other, as, for instance, 
the radius and ulna, thus preventing pronation and supination. 

Inflammation of Bones. — Inflammation may be traumatic or infec- 
tive, acute or chronic. 

Acute Traumatic Osteoperiostitis. — ^This is the expression of reaction 
against a bone bruise, characterized by localized tenderness to deep 
pressure and the formation of a subperiosteal swelling, which may 
undergo organization into bone. 

Osteomyelitis always follows a more extensive injury, such as fracture, 
and is the process essential to repair. When the neck of the femur is 
involved, the softening incident to a persistent inflammation may predis- 
pose to marked deformity. 



THE BONES 121 

Acute Infective Inflammation of the Bones. — This may appear in the 
form of an osteoperiostitis or osteomyeHtis. The usual pus organisms, 
particularly the staphylococcus, are the causative agents. Other organ- 
isms are occasionally at fault. 

Acute Suppurative Osteoperiostitis. — Acute suppurative osteoperiostitis, 
in its frankly suppurating forrn, is either traumatic or due to extension 
of inflammation from neighboring soft parts. The local and general 
symptoms are those of pus under tension, the pain being severe. 

Acute Syphilitic Osteoperiostitis. — Acute syphilitic osteoperiostitis at 
times precedes the skin eruption; usually it develops at about the same 
time. It is characterized by extremely painful, hypersensitive, slightly 
elastic swellings, involving by preference the bones of the cranium, the 
tibia, the ribs and the sternum. The overlying skin may be reddened 
and edematous. The diagnosis is based on associated syphilitic symp- 
toms. 

Typhoid Osteoperiostitis. — Typhoid osteoperiostitis exceptionally de- 
velops in an acute form, appearing as a tender, painful bone swelling, 
usually on the sternum, ribs, or tibia, preceded by severe bone pain and 
attended by moderate fever. This form of typhoid osteoperiostitis is 
prone to develop during the convalescing period. It may undergo 
resolution. Usually it breaks down, exposing an area of superficial 
necrosis. 

A^Tien it attacks the vertebrae, persistent crippling pain and disability 
are the cardinal symptoms. 

Gonorrheal Osteoperiostitis. — Gonorrheal osteoperiostitis in its acute 
form exhibits a predilection for the calcaneum, causing pain and tender- 
ness on the plantar surface of the heel. 

Acute Infective Osteomyelitis. — Acute infective osteomyelitis affects 
mainly the long bones of growing boys, particularly those of depressed 
vitality who have been subject to slight trauma or severe chilling, 
and who have an infecting focus such as a boil or an inflamed tonsil. 
The Staphylococcus aureus is the common infecting germ; in virulent 
cases the streptococcus may be found. The pneumococcus, the colon 
and the typhoid bacillus are also at times causative factors. 

Acute osteomyelitis, though it begins at or near the epiphyseal line, 
usually extends in the direction of the diaphysis. The femur and tibia 
are the bones of election. The radius, the fibula, the pelvis, the ulna, 
the inferior maxillary bone follow in order. The affection is often mul- 
tiple. Acute osteomyelitis usually terminates in necrosis, which may be 
localized or may involve the entire shaft of a long bone. Exceptionally 
it infects the neighboring joint, being then complicated by suppurative 
arthritis. It not infrequently becomes quiescent or chronic, with a life- 
lasting tendency to recurrence. Exceptionally it undergoes complete 
resolution. 

Growing pains probably represent an ephemeral form of osteomyelitis, 
especially when they are characterized by slight tenderness near one or 
more joints, recurring and starting pain and prompt subsidence under 
rest. 



122 THE nONES AHD JOINTS 

Destruction or separation of a growing epiphysis may result in de- 
formity or developmental failure. 

As the result of softening and during the period of convalescence 
spontaneous fracture is at times observed, particularly in the tibia, fibula, 
and humerus. 

As observed in infants and young children, acute osteomyelitis attrib- 
utable to infection carried from the stump of the umbilical cord or 
from other suppurating skin or mucous membrane lesion, may develop 
as an acute arthritis, the epiphyseal focus of infection promptly breaking 
into the neighboring joint. 

The diagnosis of acute osteomyelitis is based on the sudden or rapid 
development of the constitutional symptoms of virulent sepsis, asso- 
ciated with severe local pain, great tenderness, best elicited by prolonged 
deep pressure, or bone percussion, disability so complete that in infants 
paralysis is often suspected and shortly (two days) edema of the over- 
lying soft parts. Skin redness and fluctuation become obvious in the 
course of days or weeks if death from septicemia does not occur before 
this. 

The systemic infection of osteomyelitis may so closely resemble that 
of typhoid that the conditions may be confused when the seat of bone 
infection is not accessible to direct examination, as in the case of acute 
inflammation of the vertebrae, of the mastoid process of the temporal 
bone, or of the upper extremity of the femur. The leukocytosis of 
osteomyelitis is characteristic, and, if searched for, localizing symptoms 
generally can be found. 

The bone pains of the eruptive fevers and of meningitis are shortly fol- 
lowed by other characteristic symptoms; moreover, they involve many 
bones. Rheumatism involves joints primarily and is attended by rapid 
swelling and tenderness, elicited by direct joint pressure, while in osteo- 
myelitis there is usually a point of maximum tenderness in the juxta- 
epiphyseal line, and the swelling of the soft parts does not become 
obvious for two or three days. 

Chronic Inflammation of the Bone. — Chronic osteomyelitis is char- 
acterized clinically by thickening, sometimes lengthening, of the bone. 
It is usually associated with pain. It may be traumatic or infective. In 
its development it may be formative, causing pronounced overgrowth of 
bone, or destructive, as expressed by caries, necrosis, and sinus formation. 
These processes are commonly combined. The infective form is usually 
tuberculous or syphilitic. Occasionally it is an expression of either 
feeble or well-resisted pyogenic infection. 

Chronic Traumatic Osteomyelitis. — This is either a sequel of severe 
trauma inadequately treated or is incident to repeated slight trauma. 
It is characterized by pain, aggravated by use, tenderness, and bone 
enlargement, or distortion due to overgrowth or softening. This form 
of osteomyelitis is instanced by the bony deformities about the ankle and 
wrists following unrecognized fissured fractures, and by the bending 
of the femoral neck, entitled coxa vara. 

The diagnosis of chronic traumatic osteomyelitis must be based upon 



THE BONES 123 

the history of the case, the rehef of symptoms incident to rest, the findings 
of the x-rajs, and, if the case has been observed late (years), the absence 
of all tendency toward abscess formation, steady or rapid growth, or 
progressive deformity. In its earliest stages it may readily be confounded 
with tuberculous osteomyelitis. 

Chronic Infective Osteomyelitis. — Chronic infective osteomyelitis in its 
superficial form, the so-called osteoperiostitis, is usually an expression of 
syphilis, gonorrhea, typhoid, or rheumatism. 

In its deep form osteomyelitis is usually tuberculous, sometimes 
syphilitic, exceptionally an expression of the irritating effects of other 
infecting organisms, particularly those of the pus group and the typhoid 
bacillus. 

The osteoperiostitis of syphilis, an expression of the late secondary 
or early tertiary period of the disease, appears in the form of hard 
bosses, involving by preference the tibia, ulna, and the frontal and 
parietal bones, usually moderately painful, sometimes excessively so, 
slightly tender and slowly progressive (weeks) . These bosses may soften 
and discharge through a sinus, which later becomes an ulcer of con- 
siderable size, exposing carious bone, or may undergo organization, 
leaving prominent bony bosses which form permanent records of a con- 
stitutional infection, and are quite unaffected by treatment. The diag- 
nosis is based on the history of syphilis, associated lesions of the disease, 
and, in the infiltrating stage, the prompt resolution as the result of efficient 
treatment. 

Chronic Rheumatic Osteoperiostitis (rare). — This is a term applied to a 
form of bone infection in which the organism cannot be found. It is 
characterized by local pain and progressive swelling which may either 
soften slowly (weeks), discharging a serous, sterile fluid, or may undergo 
resolution, leaving thickened bone. 

Gonorrheal osteoperiostitis exhibits a predilection for the calcaneum. 
It is usually formative in nature, causing a bony outgrowth, which makes 
walking or pressure painful. Similar outgrowths are observed in the 
absence of gonococcal infection and are possibly traumatic or rheumatic. 
The diagnosis is made by the :r-rays. 

Tuberculous Osteomyelitis.^ — Tuberculous osteomyelitis is the common- 
est form of chronic bone inflammation. It is characterized by its insidious 
onset, predilection for the epiphyses of the young, slow progression, and 
ultimate destructive tendency. 

Slight trauma is the most important predisposing factor. 

Pain is usually the first symptom of tuberculous osteitis, varying greatly 
in intensity, worse at night, aggravated by use, and associated with some 
tenderness. It is at times entirely lacking, involvement of the neighbor- 
ing articulation being the first sign. 

Swelling gradually develops, forming in the case of the long bones 
of the hands and feet the spindle-shaped tumor called spina ventosa. 

On the sternum, ribs, and radius the infection may remain superficial, 
forming painless tumors which graduafly soften and discharge a cheesy 
pus through a sinus which leads to carious bone. 



124 THE BONES AND JOINTS 

The bones in their order of involvement are (Nekton) vertebrae, 
tibia, femur, humerus, phalanges, metatarsals and metacarpals, sternum, 
ribs, iliac bones, tarsals and carpals, petrous portion of the temporal 
bone. 

In the case of bones deeply placed the symptoms are usually those of 
arthritis or cold abscess which may open near the seat of bone disease 
or burrow wide of this, as, for instance, the psoas abscess of Pott's dis- 
ease, forming fluctuating tumors without appreciable symptoms of local 
inflammation. Later they ulcerate and discharge a characteristic cheesy 
pus, often with small fragments of bone. Probing or the x-rsijs lead to 
the detection of dead bone. Sometimes the tuberculous process becomes 
encysted and quiescent. 

Since in its early stage tuberculous osteomyelitis is characterized only 
by moderate pain, associated with local tenderness if the part be acces- 
sible, or, if the focus of infection be near a joint, with synovial effusion, 
the diagnosis is not possible unless destruction of bone substance has 
been sufficient to give a distinct x-ray picture. 

The causelessness and persistence of such pain and tenderness are, 
however, suggestive. 

The swelling, which shortly becomes palpable in the case of bones 
superficially placed, such as the ribs, sternum, tarsal bones, and phalanges, 
lacks the characteristics of acute infection, and, if syphilis can be ex- 
cluded, should be diagnosticated by incision and microscopic examina- 
tion, as a distinction from malignant growth is at this stage not possible. 

Since the joint symptoms of tuberculous osteomyelitis may be the first 
to attract attention to the affection, the diagnosis of the underlying lesion 
is based upon the probability of its existence, as nearly every tuberculous 
arthritis is secondary, and on the findings of the a:-rays. 

Syphilitic Osteomyelitis. — Syphilitic osteomyelitis, usually a tertiary 
manifestation of the disease, may be either circumscribed or diffuse. 
In its infiltrating stage it is a common cause of spontaneous fracture. 
It causes pronounced hyperplasia of the bone, and, if untreated, usually 
terminates in necrosis and sinus formation. The seats of election are 
the tibia, humerus, nasal septum, palate, cranial bones, and the inner 
third of the clavicle. 

When it attacks the bones of the nose, mouth, and face, it usually 
begins as a painless bone swelling, which because of its position is often 
unnoticed. The destruction of bone is extremely rapid (days or weeks), 
but is unattended by widespread acute inflammation of the soft parts or 
pronounced constitutional symptoms. Painless perforations of the palate 
and the nasal septum are in themselves almost diagnostic of syphilis. 
Gummata of the cranium at times cause intolerable anguish; usually 
they are painless. 

Syphilitic osteomyelitis of the metacarpals and phalanges is char- 
acterized usually by the almost painless development of a fusiform bone 
swelling which in the course of weeks softens and tends to discharge. 
The diagnosis between this condition and tuberculous osteomyelitis 
cannot be made from the local appearance of the lesions. The syphilitic 



THE BONES 125 

lesion is more likely to be symmetrical, involving the two hands. Both 
are observed in infants and children; either may occur in the adult. 
Tuberculous involvement is, however, somewhat more frequent at a 
later age. 

Syphilitic osteomyelitis involving the long bones is attended by the 
pain, tenderness, and, if the inflammation be near the joint, the serous 
effusion, fixation, and muscular atrophy which are regarded as character- 
istic of tuberculous osteomyelitis. 

If the syphilis manifest itself in the form of a circumscribed gumma, 
the symptoms may be identical with those of a beginning sarcoma. 

The diagnosis must be made by careful consideration of the history, 
the results of a thorough trial of specific treatment, and, in some cases, 
the findings of the a;-rays. 

The bone manifestations of hereditary syphilis are characterized 
shortly after birth by a thickening of the epiphyseal osteochondral 
plates so marked that in accessible joints distinct tumor may be felt. 
In two or three months the process of softening may reach such a stage 
as to cause juxta-epiphyseal fracture, usually characterized by a pseudo- 
paralysis, since there may be no displacement because of the thickened 
periosteum, nor bone crepitus. A child of six months presents precisely 
the appearance of one suffering from rickets. 

Periosteal outgrowths, sunken nose, high vaulted palate, and sabre- 
shape nodular tibias represent typical results of the hereditary form of the 
disease. 

Chronic osteomyelitis which is neither syphilitic nor tuberculous is 
commonly a sequel to an acute attack, and is due to the ordinary pus 
organisms, exceptionally to other forms of microbian infection. The bone 
is always thickened, sometimes enormously so, about the area of suppura- 
tion or necrosis, the pus often being found sterile to bacterial investiga- 
tion. There may be a large sequestrum unattended by suppuration. 
The affection is characterized by pain located in the bone, aggravated by 
use and subject to periods of exacerbations; swelling of bony hardness, 
which may be found only in the epiphyseal region, shading off gradually 
into the diaphysis, or which may involve the entire shaft, tenderness 
often elicited only by deep and prolonged pressure or by percussion, and 
by somewhat characteristic a;-ray showings. 

The favorite seats of circumscribed abscess are at either extremity of 
the tibia, particularly the upper, and the lower extremity of the femur. 
When the condition is associated v/ith a serous effusion into the nearest 
joint the distinction from tuberculous osteomyelitis may be quite impos- 
sible without exploratory and curative operation. 

Malignant growth in its early stage affords precisely the clinical pic- 
ture of a localized chronic osteomyelitis, excepting that the onset and 
progression of the newgrowths are more rapid. When tumor has 
developed, neoplasm always gives a more distinct outline from the sur- 
rounding bone than is afforded by the overgrowth of tissue incident to a 
chronic osteomyelitis. 

The diagnosis, suggested by a previous acute attack of osteomyelitis, 



126 



THE BONES AND JOINTS 



should be made by the a;-rays and by early incision, providing gumma 
can be excluded. 

Rickets. — This is an affection of infancy, but sometimes of late devel- 
opment, supposed to be due to malnutrition, common in those of syphilitic 

parentage. Its acute form (rare) 
Fig- 41 is characterized by painful swell- 

ing of the ends of the long bones, 
usually diagnosticated and treated 
as rheumatism. 

The customary mode of onset 
is by gradual impairment of health, 
juxta- epiphyseal bone swellings, 
and mechanical deformities incident 
to softening. 

A rickety child exhibits a bossed 
forehead, open fontanelles, delayed 
dentition of deformed and rapidly 
rotting teeth, high palatal vault, 
alveolar flaring in the upper jaw, the 
reverse of this in the lower, beaded 
ribs (rachitic rosary), chicken breast, 
pot-belly, spinal curvature, usually 
anteroposterior, and enlarged epi- 
physes. 

The distinction from hereditary 
syphilis by the symptoms alone is 
impossible. 

Osteomalacia. — Osteomalacia, an 
affection of adults, exceptionally 
observed in children and in the 
aged, sometimes epidemic, most 
frequently affects gravid women 
who have borne many children in 
quick succession, and is character- 
ized by tenderness, softness, and 
flexibility of the bones and rapid loss of height, associated with impaired 
general health, cutaneous hyperesthesia, and exaggerated reflexes. 
Spontaneous fracture is common and exhibits little tendency toward 
healing. From gravity and the pull of muscles, deformities are rapidly 
developed, particularly curvature of the spine. Exceptionally, multiple 
cysts are found in the bone, forming symmetrical tumors. 

The diagnosis in the early stage may be suggested by distinct and wide- 
spread bone tenderness and pain. Later, when the bones become flexible, 
deformities are produced, and spontaneous fractures occur, at least the 
name of the malady is readily suggested. 

When it attacks the aged, osteomalacia is particularly characterized 
by bone pain and tenderness involving especially the ribs and spine, 
associated with muscular contracture, inducing anteroposterior curva- 




Rickets. Large head; protuberant abdomen 
bowing of tibiae. (Carnett.) 



THE BONES 127 

ture. There is almost complete helplessness. This is particularly the 
case when the condition, as is common, is associated with spontaneous 
fracture. 

Osteitis Deformans. — Osteitis deformans, or Paget's disease, an affection 
of the elderly, usually associated with arteriosclerosis, and indicative of 
a predilection toward malignant growth of the bone, is characterized by 
deformities which are due to combined processes of absorption and 
overgrowth. The bones of the leg are the first to be obviously affected, 
though an early symptom attracting attention may be the need for 
getting a hat of larger size. As a rule, pain located in the bone, at times 
of exhausting severity, initiates the affection, followed in the case of the 
legs by weakness, stiffness, and bowing and thickening of the diaphyses 
of the long bones, is usually symmetrical. The progress of the dis- 
ease is slow (years). It may remain in the part first affected or may 
become generalized. The diagnosis is based on the dissemination of 
the lesions and their slow progression. 

From syphilitic osteomyelitis the affection is distinguished by its much 
slower course, its wide diffusion, the absence of a tendency to necrosis and 
sinus formation, and failure to respond to specific treatment, though the 
latter will be equally futile even in cases of syphilis when the formative 
changes incident to irritation have reached their complete development. 

Achondroplasia is a congenital aft'ection akin to rickets in its bone 
manifestations. 

The few children who survive are symmetrically headed, long-bodied, 
pot-bellied dwarfs, with short extremities and big epiphyses. 

Osteogenesis Imperfecta.^ — Osteogenesis imperfecta is a congenital 
affection characterized by multiple fracture incident to imperfect bone 
formation. Children who survive are of low stature and are short- 
legged. The diagnosis is based on the occurrence of multiple fractures 
from inadequate cause. 

Acromegaly. — Acromegaly is a chronic painless affection due to 
disease of the pituitary body, insidious in onset, slow in progress, and 
characterized by gigantic growth of the hands, feet, face, and head. 
The soft parts participate in the overgrowth of bone, though the 
nails remain of normal size. The gross face, projecting eyebrows, big 
tongue, large nose, bulging occipital protuberance, enlarged mastoid 
processes, thick lips, and coarse features are characteristic. There is 
an associated testicular atrophy in men; in women, enlarged clitoris 
and vagina and hyper trophied larynx, giving them a bass voice. The 
thymus gland is enlarged. 

Perhaps the most diagnostic feature of the affection is the slow and 
apparently causeless increase in the size of the hands and feet. 

Tumors of the Bone. — Osteoma. — Osteoma, a benign tumor of slow 
growth and extreme hardness, is usually fixed to the underlying bone. 
Either local or diffuse hyperostosis is a common expression of chronic 
inflammation. During the period of epiphyseal growth and consolidation, 
usually before puberty, exostoses, often spur-shape, but exhibiting great 
diversity of conformation, and capped with cartilage, develop, origin- 



128 THE BONES AND JOINTS 

ating near the epiphyseal line and growing toward the diaphysis. These 
cease growing when the epiphyses have reached full development. Their 
seats of predilection and greatest development are the bones of the fore- 
arms and legs, though they may occur toward the extremities of any of 
the long bones. They are characterized by causelessness, multiplicity, 
slow growth ceasing with maturity and absence of symptoms aside from 
those incident to their bulk. 

The affection is often hereditary. 

The diagnosis of all forms of osteomata is based on the slowness of growth, 
the absence of symptoms other than those incident to mechanical inter- 
ference and pressure, the a;-rays and excision and microscopic examina- 
tion. Exceptionally after injury about the knee there is a comparatively 
rapid development of a tender painful osteoma. This can be distin- 
guished from beginning sarcoma only by excision and microscopic 
examination. 

Exostoses of the sinuses of the cranial bones conform to type in that 
they develop slowly, usually in young adults, and manifest their pres- 
ence only by pressure symptoms, usually beginning with a sinusitis, later 
followed by tumor developing in the case of the frontal sinus in the 
direction of the orbit. The x-rays give a characteristic picture. 

Chondroma. — Chondroma, often an hereditary affection, has for its seat 
of predilection the bones of the hands and feet. The tumor may be 
single or multiple, and frequently gives a traumatic history. 

Chondromata are characterized by the slow (years) growth of a painless, 
usually lobulated, hard, elastic tumor, which, if subperiosteal, may be 
covered by a thin shell of bone. Pressure ulcers may occur in the soft 
parts when the tumor has attained great size. 

The centrally placed enchondromata may give rise to severe pain and 
spontaneous fracture. Moreover, in their transitional (usually malignant) 
forms these tumors may become soft and grow rapidly. 

The distinction from sarcoma in the early stage of the growth should 
be made by excision. Later, the slow extension of the chondroma, 
distinct encapsulation, and sometimes enormous size are sufficiently 
characteristic of the nature of the tumor. 

In its pelvic development chondroma commonly springs from near 
the sacroiliac synchondrosis, exceptionally from the pubic region. 
Growth is rapid and characterized by density, fixation, and pressure 
symptoms, particularly in the direction of the sciatic and obturator 
nerves. The distinction from malignant growth can be made only by 
excision. 

Lipoma. — Lipoma of the bone (rare) may be congenital, inflammatory, 
or neoplastic. The congenital lipoma may be placed at or near the 
epiphyses, particularly that of the upper portion of the femur. It may 
be pedicled or sessile and not infrequently causes bone erosion. This 
form of lipoma may grow rapidly. It is characterized by the softness 
typical of lipomata. It is prone to recur, and apparently produces a 
cachexia almost as profound as that of malignant growth. 

Diagnosis can be made only by operation. 



THE BONES 129 

Lipomata growing from the bones of the head and spine are usually 
the remains of cured meningocele. 

The bone lipoma of the adult is characterized by the softness, lobula- 
tion, slow growth, and absence of subjective symptoms characteristic of 
this form of tumor. 

Sarcoma. — Sarcoma is the commonest bone tumor. It is usually single, 
developing in youth and early manhood. It is observed in infancy, 
and may be prenatal. It is usually most malignant in young subjects. 
The favorite seats are the jaw, femur, tibia, radius, and humerus. The 
epiphyseal extremities of the long bones, particularly those about the 
knee, are the seats of predilection. 

The diagnosis of sarcoma is based on pain, tumor, and the a;-ray 
findings (pp. 41 and 43). Pain is fixed, persistent, often referred to the 
neighboring joint, and is generally treated as rheumatic. These symp- 
toms may precede the development of tumor by weeks or months. 
The tumor may be globular or fusiform, hard or soft, and in the case 
of central sarcomata, often gives an egg-shell crackling which in itself 
is not diagnostic of malignancy. In highly vascular cases there is 
both pulsation and bruit. In rapidly growing cases there is a distinct 
rise in temperature, both local and general. Fracture is common in 
central sarcomata, and may be the first pronounced symptom to call 
attention to disease of the bone. In periosteal sarcomata, tumor may be 
observed early. It does not encircle the bone, has fairly abrupt margins, 
and is more regular in outline and rapid in development than either 
osteoma or chondroma. 

Sarcoma of the bone is usually central, and, if of the giant-cell type 
(common), is relatively benign; exceptionally it gives metastases and 
recurs after thorough operations. Central spindle-cell sarcoma (rare) 
is also of relative benignancy. The central round-cell sarcoma is highly 
malignant, as are the periosteal sarcomata. 

The diagnosis of sarcoma may be suggested by the rr-rays, but can be 
made certainly only by excision and microscopic examination, the latter 
facilitated by a freezing microtome, made at the time of operation, since 
the form of intervention depends upon the type of growth. The macro- 
scopic appearance of some of these tumors is sufficiently characteristic 
of relative benignancy to enable a probably wise decision to be made 
between local excision and amputation wide of the disease. The giant- 
cell sarcoma is usually completely enclosed in a capsule of bone, on break- 
ing through which there is exposed a vascular pulp which bleeds furiously. 
The limitation of the more malignant growths is less distinct. 

Myeloma. — Myeloma exhibits an early predilection for bones of the 
thorax, including the vertebrae. It is characterized by the multiplicity 
of its lesions and albumosuria. Distinction from sarcoma may be made 
clinically on this basis. 

Endothelioma. — Endothelioma presents the characteristics of central 
sarcoma. Nor can a distinction be made excepting by microscopic 
examination. The affection is one of middle age, and is likely to be 
multiple. 
9 



130 THE BONES AND JOINTS 

Carcinoma. — Carcinoma of the bones is always secondary, usually 
to cancer of the breast, prostate, or thyroid. These metastases may 
occur, particularly in the case of the prostate or the thyroid, before 
the primal focus has reached sufficient dimensions to excite clinical 
symptoms. 

Diagnosis is based on pain and swelling; there is often spontaneous 
fracture. Thyroid metastasis is commonly observed in the sternum, 
bones of the skull, the humerus, and the vertebrse. The prostatic 
metastasis is commonly manifest in the vertebrae. 

The bone manifestations of hypernephroma are those of malignant 
disease. The distinction must be made with the microscope. 

Bone Cysts. — Bone cysts (rare) develop in the shafts of long bones 
during youth near the epiphyseal line, particularly in the tibia, femur, and 
humerus. They are characterized by a tendency to spontaneous fracture, 
often by pain of moderate severity, and by the gradual formation of a 
fusiform tumor made up of a single fibrocartilaginous sac containing 
bloody fluid, surrounded by a thin cortex and normal periosteum. 

The diagnosis is based upon slow growth (months, years), the a:-rays, 
and by incision. 

Multiple bone cysts are frequently found in the bones of osteomalacia, 
while cystic degeneration is common in sarcomata and enchondromata. 

Dentigerous Cysts. — Dentigerous cysts, originating in the jaws, form 
slowly growing bone swellings extending in the direction of the outer 
surface of the jaw, occurring in young adults who on examination show 
the absence of a tooth. They cannot be distinguished clinically from 
dermoid cysts nor, excepting by operation, from sarcoma. 

Echinococcus Cysts. — Echinococcus cysts are rare, and can be diag- 
nosticated only by operation. 

Fibromata. — Fibromata of bone, with the exception of certain forms 
of epulis and nasopharyngeal growths, are rare. The latter condition 
is observed mainly in young men under twenty-five years of age. The 
slow growth and dense consistency of fibromata are thoroughly character- 
istic, but diagnosis must be made by excision and microscopic examina- 
tion, since the distinction cannot otherwise be made from fibrosar- 
coma. 

Fat Embolism. — Fat embolism is an occasional complication of bone 
lesions such as are accompanied by extensive crushing of the medulla, 
as in fracture of the lower end of the femur. It may follow operation 
upon bone. It is characterized by acute edema of the lungs, coming on 
suddenly some days after bone injury. Signalized by dyspnea, often 
accompanied by coughing up of blood-stained serum indicative of infarct, 
and by a rapid, labored heart action, right-sided dilatation and vertigo, 
apathy, or even loss of consciousness (Forgue). The diagnosis is based 
upon the sudden onset of all such symptoms following bone trauma and 
the finding of fat in the urine which appears on its surface as a cloudy 
deposit made up of fat globules, which maybe demonstrated by staining 
with osmic acid. 



THE JOINTS 131 



THE JOINTS. 



Traumatism. — Contusion. — Contusion may be from direct or indirect 
violence. In the latter case the major lesion is a bruising of the 
articular surfaces often associated with fracture; in the former case the 
soft parts exhibit the major evidences of traumatism. 

The symptoms of joint contusion are: tenderness on pressure and 
motion, severe pain, disability, and rapid swelling which, if the joint be 
accessible to palpation, can be felt to be mainly intra-articular. 

Rapid (minutes or hours) swelling, severe, persistent pain, absolute 
disability, excessive tenderness, are presumptive evidences of fracture. 

Rapid and extensive effusion into a joint as the result of slight contu- 
sion or sprain is suggestive of hemophilia. This suggestion becomes 
almost a certainty if there is but slight pain and disability, the major 
symptom being swelling due to rapid capsular distention, associated 
with a history of prolonged bleeding from slight wounds. 

The diagnosis of joint contusion is made by the a:-rays and by prompt 
recovery as the result of rest. 

Chronic arthritis following contusion is an expression of recurring 
trauma from hypertrophied synovial fringe, loose body, fracture, etc., 
or of the localization of a toxin or infection at a point of lessened 
resistance (gout, rheumatism, tuberculosis). 

Sprain. — This implies sudden overstretching of periarticular soft parts, 
often associated with a tearing away of bony attachments and bruising 
of the joint surfaces. The wrist and ankle are the usual seats. It is 
characterized by disability, severe pain, swelling, tenderness most marked 
at the seat of tear, and late discoloration. 

Exaggeration of local symptoms, and especially their persistence, is 
presumptive evidence of complicating fracture or the localizing in an 
area of lessened resistance of systemic toxemia or infection. 

Since the diagnosis in severe cases calls for the elimination of 
fissured fracture, this usually requires the help of the a;-rays. 

Wounds of Joints. — The diagnosis is usually obvious or may be sug- 
gested by escape of synovial fluid. 

Punctured wounds, as from a dirty needle, may cause a serous or sero- 
fibrinous effusion, characterized by distention of the capsule, tenderness 
and limitation of motion, or the most virulent type of purulent arthritis. 

When infection has taken place, this may remain latent until the second 
or third day when symptoms of acute suppurative inflammation, both 
local and constitutional, develop rapidly. In hyperacute cases inflamma- 
tory symptoms develop within twenty-four hours. This is particularly 
the case when there is a large effusion into the joint. 

Dislocation. — Dislocation, rare in the young and the old, may be trau- 
matic or pathological. The latter as a consequence of disease; usually 
an abundant intra-articular effusion, extensive bone destruction, or both. 

The diagnostic features of traumatic dislocations are: marked defor- 
mity, usually appreciable on inspection and palpation; elastic fixation; 



132 THE BONES AND JOINTS 

alteration of the axis of the bone luxated in relation to that of the bone 
with which it should articulate, and either lengthening or shortening. In 
addition the symptoms common to all traumata are present, i. e., pain, 
swelling, tenderness, disability, great discoloration. 

On palpation the articular extremities of the bone can usually be felt 
not in their proper relation one with the other. This in the case of deep 
joints or great tenderness and swelling may not always be easily demon- 
strated. 

Distinction from contusion, sprain, and fracture is made by the ic-rays 
and examination under ether. Elastic rigidity is contrasted with the 
preternatural mobility of fracture, the rounded joint ends with the 
jagged ones of fracture, the deformity is of the joint itself and not simply 
near it, and the deformity, reduced with difficulty and often with a 
sudden jar or slip, does not recur immediately on removal of the traction 
or support. 

Complicating fracture in or near the joint often requires the ^-rays for 
its diagnosis. Injuries of neighboring nerves and vessels should be 
detected at the time of first examination. 

From epiphyseal separation, dislocation is distinguished by the fact 
that the epiphyseal separation is an affection of youth, there is no elastic 
fixation, but rather preternatural mobility, the deformity is easily reduced, 
and as readily recurs on removing traction or support. 

Pathological luxation may be concealed by the swelling and deformity 
incident to the causative lesion (caries, necrosis, hydrops or rheumatoid 
arthritis). 

The power of voluntary, usually incomplete, luxation is sometimes 
seen developed to an extraordinary degree, and is due to the unusual 
laxity of the ligaments. This maneuver is commonly dependent upon 
long practice. 

Congenital luxation, commonest in the hip, is the result of imperfect 
fetal development, and is often combined with other deformities. It is 
most frequent in females, is usually unilateral, and is obvious by com- 
parison of the trochanters of the two sides. When bilateral the diagnosis 
may necessitate the use of the x-rays. 

Arthritis. — Arthritis may be traumatic (a single severe or slight 
repeated injury); secondary to inflammation of neighboring structures, 
particularly the epiphysis; a local expression of systemic infection 
or toxemia (rheumatism, pyemia, typhoid, gonorrhea, la grippe, gout, 
pneumonia, tonsillitis, any focus of suppuration); neuropathic (tabes, 
syringomyelia, peripheral nerve inflammation or injury); or incident to 
the nutritional changes of arteriosclerosis (senile arthritis deformans). 

In its clinical manifestations it may be acute or chronic. The exudate 
may be serous, fibrinous, or purulent. 

The type of acute serous arthritis, often called synovitis, because the 
synovia exhibits the principal lesions, is characterized by more or less 
abundant effusion, often slightly turbid because of the mixture with 
endothelium and fibrin. The synovia is markedly congested and often 
infiltrated with leukocytes and even with extravasated blood. There is 



THE JOINTS 133 

heat, tenderness, swelling, and fluctuation, with fixation of the joint in 
the position allowing of greatest distention (usually slight flexion), great 
pain on motion, rigidity of muscles, and usually some atrophy. This 
type of arthritis follows traumatism, either from external violence, in 
which case the effusion usually contains blood, or from pinching of the 
articular surfaces incident to loose bodies in the joint. It is also the 
commonest expression of systemic infection, particularly of that form 
called rheumatic fever. Typhoid, la grippe, pneumonia, gonorrhea, even 
pyemia, may in their joint expression be characterized by serous effusion. 
Even an acute juxta-articular suppurative osteomyelitis, unless the pus 
breaks directly into the joint cavity, may be attended simply by a serous 
arthritis. 

The fibrinous exudate is characterized by the same symptoms ; the 
distention of the joint capsule is less marked, there is no fluctuation 
even in accessible joints, but the periarticular swelling is greater. Pain 
is more intense, fixation and muscular atrophy develop rapidly, and 
the affection runs a much more chronic course, frequently resulting in 
permanent fixation. 

Traumatism when associated with intra-articular bone lesions may be 
characterized by a fibrinous exudate. This form is a frequent expression 
of la grippe and gonorrhea, an occasional one of other forms of infec- 
tion. 

Purulent arthritis commonly follows a serous effusion, or may be puru- 
lent from the first. The pain is intense, the muscular fixation absolute. 
The periarticular heat, redness, and swelling are more marked and 
rapidly progressive, constitutional symptoms are profoundly septic, and 
the joint structure is rapidly destroyed. 

This form of arthritis is usually incident to an infected wound or is 
secondary to suppuration of structures near the joint (osteomyelitis, 
tenosynovitis). 

In mild cases, and this is particularly true of the acute suppurative 
synovitis of small children and of the suppurative arthritis secondary to 
pyemia, the infection remains confined to the joint, and, if this be promptly 
drained, joint function may be restored. 

It is an occasional local expression of pyemia and exceptionally one 
of pneumonia or gonorrhea. It is possible in any form of infectious 
arthritis. 

The diagnosis is based upon hyperacute local inflammatory symptoms, 
with rapid and progressive involvement of the soft parts and the consti- 
tutional symptoms of profound sepsis associated with polymorphonuclear 
leukocytosis. 

Acute Traumatic Arthritis. — Acute traumatic arthritis, incident to con- 
tusion, wrench, or the pinch of a locked loose body, attended by a serous 
or sanguinoserous effusion, is characterized by fixation, pain on joint 
palpation and movement, and, where the capsule is palpably near the 
surface, fluctuating swelling. In the absence of bone lesion, repeated 
trauma, or gouty or rheumatic diathesis the recovery is prompt and 
complete. 



134 THE BONES AND JOINTS 

Wounding of the joint may lead to acute suppurative arthritis charac- 
terized by the local and constitutional symptoms of retained pus. 

Acute Rheumatic Arthritis. — ^Acute rheumatic arthritis is a local ex- 
pression of a constitutional toxemia or infection which begins with chill 
and fever, not remittent, accompanied or shortly followed by pain, 
tenderness, swelling, fixation, and in severe cases, heat and redness of 
one or more of the larger joints. 

The arthritis is usually multiple and shifts from joint to joint, though it 
may be monarticular. Acid sweats are regarded as characteristic, 
and endocarditis is such a frequent complication that its development 
is of diagnostic value. 

In children the onset is less abrupt, the joint symptoms not so well 
marked, and the inflammation may exhibit little tendency to flit from 
joint to joint. It is at times associated with tonsillitis. 

The monarticular type of rheumatic arthritis can be distinguished from 
acute suppurative arthiitis by the more profound sepsis of the latter con- 
dition and the rapid progression of local symptoms. 

Acute Gouty Arthritis. — Acute gouty arthritis is characterized by the 
suddenness of an acute attack, particularly of the metatarso-phalangeal 
joint of the great toe, accompanied by rapid swelling, heat, and red- 
ness of the skin. The attacks are transitory but recurrent, affect the 
small joints by preference, are unattended by pronounced constitutional 
symptoms, and are often accompanied by palpable urate nodules about 
joints other than the ones acutely inflamed. 

The finding of glycocoU in the urine with diminution in the amount 
of uric acid is said to be characteristic (Hirschstein). 

Acute Gonorrheal Arthritis. — Acute gonorrheal arthritis, either mon- 
articular or polyarticular, affects the knee by preference. The ankle, the 
shoulder, the wrist, the hip, and the joints of the fingers and toes come 
next in order of frequency. It is a complication of posterior urethritis, 
and occurs usually after the third week of disease. 

The effusion is serous or fibrinous. In the former case the swelling 
is confined to the joint; it may be persistent or recurrent; when acces- 
sible, is distinctly fluctuating; pain and disability are moderate. 

The fibrinous exudate is attended by severe pain, prompt fixation, 
pronounced peri-articular swelling attended by heat and redness, and 
rapid muscular atrophy. 

The diagnosis of gonococcal arthritis is made by finding a focus of 
infection. This is usually in the glands and follicles of the posterior 
urethra, the ampulla of the vas or the seminal vesicles. 

Exceptionally suppuration due to mixed infection occurs accompanied 
by the local or constitutional symptoms of this condition. 

The polymorphonuclear leukocytosis and, in case of aspiration, the 
examination of the joint contents indicate the condition. The rapid 
progression of the local inflammatory symptoms in suppurative cases 
is characteristic. 

From gonorrheal arthritis the rheumatic form is distinguished by its 
more acute fever, acid sweats, and polyarticular expression in larger 



THE JOINTS 135 

joints. Gonorrheal arthritis may exhibit the same features. The 
differential diagnosis is then dependent on the presence of a focus of 
gonococcal infection (urethra, conjunctiva). 

Acute Arthritis Deformans. — Acute arthritis deformans, observed in 
the badly nourished, particularly in overworked and inadequately clad 
young women, is characterized by fever (exceptionally none), pulse 
hurry, and simultaneous development of acute inflammatory symptoms 
in a number of joints, both large and small, but particularly those of the 
fingers and toes. In one form of the affection, usually observed in children 
(Still's disease), there is enlargement of glands into which the inflamed 
joints drain and tumefaction of the spleen. This form of arthritis does 
not undergo resolution, but persists in a chronic form, often with acute 
exacerbations, ultimately (months or years) causing stiffening, deformity, 
and distortion. 

The diagnosis from acute rheumatic arthritis can be made only by the 
persistence of the inflammation. 

Typhoid Arthritis. — Typhoid arthritis in its polyarticular form may 
closely simulate acute rheumatic arthritis. It usually develops during 
the acute or subsiding stage of the fever; or not until a late period of 
convalescence. 

In its monarticular form it commonly involves the hip, resulting in a 
chronic serous effusion which may be so great as to cause luxation. The 
symptoms of arthritis are not well marked, and, if the affection occurs 
during the period of profound systemic depression, neither pain, tender- 
ness, limitation of motion, nor disability may be noted. The swelling is 
obscured by the deep position of the joint. 

The diagnosis is based on the presence of an arthritis following typhoid 
fever and not accounted for on other grounds. 

Typhoid arthritis may be of the suppurative type incident to mixed 
infection. 

Scarlet fever arthritis so closely simulates the rheumatic form of the 
affection that in the absence of sore throat, of rash and characteristic 
rapid pulse, diagnosis cannot be made. 

Influenza arthritis closely corresponds to that complicating gonorrhea 
in both symptomatology and development. Its diagnosis is dependent 
upon its association with influenza. 

Pneumococcic arthritis develops in from two to fifteen days from the 
onset of acute pneumonia (Cave). Exceptionally it precedes the lung 
involvement or may even occur independent of this inflammation. It 
usually suppurates and is attended by a large mortality, due probably to 
the major disease. 

In the absence of lung involvement the diagnosis must be made by 
microscopic and bacterial examination of the joint contents. This is not 
infallible. 

Acute Tuberculous Arthritis. — ^Tuberculous arthritis occasionally 
develops in the acute form. The diagnosis can be made only by micro- 
scopic examination and inoculation of the joint contents into susceptible 
animals. Estimation of the opsonic index (less than 0.8 or more than 



136 THE BONES AND JOINTS 

1.2) may be useful. A precediug tuberculous periarthritis or tubercu- 
lous lesions elsewhere are suggestive. 

Acute hemophilic arthritis is characterized by pronounced acute joint 
effusion without adequate cause, attended by at most slightly marked 
inflammatory symptoms and followed by late ecchymosis. It occurs in 
young subjects who in most cases give a history of free bleeding from 
trivial wounds, and more than one joint is commonly affected, though 
not synchronously. 

The affection is recurrent and ultimately results in pronounced dis- 
ability and extensive deformity. The diagnosis is suggested by the 
characteristics given, but is usually made on aspiration of the joint. 

Acute purulent arthritis of infants, from the first to the fourth year, 
is common in the hip, shoulder, and elbow, and is a joint expression of 
neighboring osteomyelitis. 

The joint effusion may be serous; this can be determined by aspiration. 
It is usually purulent, and is indicated by an increase in the local and 
constitutional symptoms, fixation of the joint, and rapidly progressing 
edematous swelling of the soft parts surrounding it. Unlike purulent 
arthritis at a later age, after drainage the functional prognosis is 
good. 

Chronic Arthritis. — Chronic arthritis incident to repeated slight trau- 
matism, sequent to an acute attack, due to a persistent or recurring 
infection or toxemia, consequent to nerve lesion, or secondary to arterio- 
sclerosis, is characterized by muscle atrophy, partial or complete fixation 
(exceptionally preternatural mobility), and deformity. The changes 
may be atrophic or hypertrophic so far as the bone and cartilage are 
concerned, but in either case the joint capsule is greatly thickened. 

Chronic traumatic arthritis, when it follows the acute form of this 
affection, is usually incident to an injury to ligament, bone, or cartilage 
resulting in a healing which puts the joint at a mechanical disadvantage 
when it is used. Such an arthritis is often expressed in the form of a 
serous effusion (hydrops) which may be persistent or subject to apparent 
cure and frequent relapses. In the latter case, particularly if the relapses 
are attended by subacute or acute inflammatory symptoms, loose body 
(joint mouse), displaced cartilage (knee, jaw), or thickened synovial 
fringe should be suspected. Slightly traumatized joints are susceptible 
attacks of gout, rheumatism, tuberculosis, and the various infections 
which have joint manifestations. 

Chronic arthritis deformans of either the atrophic (rheumatoid arthritis) 
or hypertrophic (osteoarthritis) type may follow an acute attack resem- 
bling inflammatory rheumatism, or may develop insidiously from the first. 
Swelling, stiffness, and deformity are slowly (years), often irregularly, 
progressive, or the disease may be arrested. 

The affection may be polyarticular or monarticular. 

The former variety involves the joints of the fingers and toes, and 
exhibits a tendency toward centripetal joint extension. Observed in 
children it is often of the fibrinous and ankylosing type, with an 
acute onset. 

The monarticular form, an affection of the elderly, has a predilection 



THE JOINTS 137 

for large joints, particularly the knee and hip. In this type the bone 
and cartilage proliferations are usually pronounced. Joint grating, 
synovial effusion, and loose bodies are common accompaniments. 

The diagnosis of arthritis deformans is based upon the persistence of 
joint symptoms and the gradual development of permanent lesions either 
following an acute artliritis or developing gradually. In the latter case 
there is recurring joint stiffness, at first intermittent, and usually most 
marked after periods of disuse, as in the morning, followed by gradual 
deformity, limitation of motion, and muscular atrophy. Not infrequently 
distortion results from muscular contracture, cicatricial contraction of 
periarticular structure, or alterations in the conformation of the ends of 
the bone. 

Bony nodulations of the interphalangeal joints, particularly the 
distal ones (Heberden's nodes), are regarded as especially character- 
istic. They may remain the only evidences of joint involvement, causing 
little inconvenience and unattended by obvious inflammation or deformity 
of the joints near which they are placed or of any other articulations. 
Similar bony outgrowths are observed about the phalangeal joints after 
trauma. The nodular deposits of gout, if deeply placed, cannot be 
distinguished by palpation from these nodes. 

Since the etiology of the affection, variously termed arthritis deformans, 
chronic rheumatoid arthritis, osteoarthritis, nodular rheumatism, etc., 
is entirely unknown, the differential diagnosis, according to types and 
names, seems unnecessary. There is reason to suppose, as is the case 
with acute joint affections, that these chronic lesions are secondary to 
infection or toxemia, nor should the diagnosis be regarded as complete 
until the sources of possible infection or of auto-intoxication are elimi- 
nated. 

By the aid of the x-rays the type of joint involvement, i. e., atrophic 
or hypertrophic, may be determined, also the differential diagnosis of 
those forms of obscure etiology from those which are known to be 
infectious, particularly from tuberculous arthritis. 

Chronic gouty arthritis, usually a sequel of recurring acute attacks, 
corresponds to the general type of arthritis deformans in that the joints 
of the toes and fingers, later those more centrally placed, are involved in 
a deforming and crippling arthritis. Gout is, however, characterized by 
periarticular deposits of uric acid (tophi), which may also be found in the 
ear, and patients thus afflicted usually have Bright's disease and arterio- 
sclerosis. 

The diagnosis from other forms of osteoarthritis is based upon the 
presence of the tophi. 

Chronic tuberculous arthritis is usually an affection of young males and 
frequently follows slight trauma. Its characteristic symptoms are fixation 
of the joint, or at least limitation of its motion, and muscular atrophy 
with pain which is often referred. 

The time when this affection should be diagnosticated is when there is 
little or no effusion into the joint, no blurring of its outlines, no consti- 
tutional symptoms, and at the most a limitation in motion and conscious 
or unconscious saving of the part, some tenderness, and muscular atrophy. 



138 THE BONES AND JOINTS 

A chronic monarticular arthritis of a child is usually tuberculous. 
The joints of election are those of the spine, hip, knee, ankle, and elbow. 

Since the tuberculous affection is usually primary in the epiphysis, 
involving the joint later, the x-rays will often detect a lesion before the 
joint is infected. In appropriate cases the tuberculin test and the 
opsonic index will be found serviceable. 

Arthritis deformans in its monarticular form is an affection of the 
elderly, the slow (years) progression of which is characteristic; still 
more so the absorption and hyperplasia of the bones and cartilages as 
shown by the cc-rays. 

The symptoms of chronic traumatic arthritis are so like those of early 
tuberculous arthritis that prompt diagnosis must be made by the o^-rays 
or aspiration of fluid and injection into susceptible animals. 

Syphilitic arthritis is usually secondary to gummatous osteomyelitis. 
In its development it corresponds closely to a local tuberculosis. Nor in 
adults does it conform to the type of tertiary lesions, which are usually 
painless. 

In children hereditarily syphilitic, an almost painless chronic inflam- 
mation of the knee, elbow, hip, or shoulder, characterized by a non- 
sensitive swelling and accompanied by marked disability is a common 
expression of the constitutional disease. 

A preceding history of syphilis, other signs of the disease, and, before 
the destructive and cicatricial stage, the curative effect of appropriate 
treatment are of diagnostic value. 

Neuropathic arthritis is usually secondary to tabes or syringomyelia. 
It may follow trauma or complicate neuritis. 

Tabetic arthropathy commonly affects the knee, the hip, and the ankle; 
exceptionally it involves the joints of the upper extremity. There is an 
atrophic and a hypertrophic form. Diagnosis is based upon the absence 
of pain and the inadequacy of cause for an abundant exudate or a greatly 
deformed joint which may be preternaturally mobile or dislocated. 
From hemophilic arthritis the affection is distinguished by the associated 
symptoms of tabes. 

Syringomyelic arthropathy occurs in the upper extremities of men of 
advanced years. The progress is slower than in tabes, the deformity is 
pronounced, even monstrous, osteophytes being common, and dislocation 
is frequent. Analgesia is a prominent symptom. 

Free Bodies in the Joint. — ^These may be fibrinous, fibrolipomatous, 
cartilaginous, or bony. 

Fibrinous concretions, the result of previous inflammation, are often 
multiple and individually attain considerable size. Exceptionally, free 
bodies are found in healthy joints. Usually in those which have been 
subject to chronic inflammation. The knee and elbow are common seats. 

The affection is characterized by synovial effusion, thickened capsule, 
and the detection of the movable body by palpation. Mechanical locking 
of the articulation causes recurring attacks of sudden, often excruciating, 
pain brought on by certain movements of the joint, accompanied by 
fixation, which is temporary, and is followed by synovial effusion. 



THE JOINTS 139 

The diagnosis can usually be confirmed by the a;-rays. The patient 
often makes it himself. 

Joint Neurosis. — Under this title, termed also hysterical joint, are 
classed affections which, though mimicking those of an inflammatory 
nature, are found on attentive and repeated examination to depart from 
type. The knee, hip, and shoulder are the seats of election. The major 
complaint is usually pain associated with tenderness and at times surface 
heat and redness. Slight trauma is a common predisposing factor. In 
the more severe forms there may be fixation, atrophy, and contracture, 
associated with vasomotor disturbances. 

Diagnosis is based upon the negative evidence of the a:-rays, the absence 
of inflammatory symptoms, the disappearance of contractures under an 
anesthetic, variability of symptoms, and the association of other hys- 
terical phenomena. 

Lipoma is occasionally observed in the joint, usually attended by a 
moderate degree of synovial effusion and acting as a loose body. The 
diagnosis is usually made by excision. 



CHAPTEK XI. 

DISEASES OF THE NERVOUS SYSTEM. 
By T. H. WEISENBURG, M.D. 

In this chapter will be discussed those neurological affections which 
are either amenable to surgical treatment or in which such procedure 
is considered justifiable. The general principles upon which neuro- 
logical diagnoses are based, and only so much of the histology, anatomy, 
physiology, and pathology of the nervous system as is needful for 
diagnostic purpose are given 

PHYSIOLOGICAL ANATOMY. 

The nervous system consists principally of the brain and spinal cord 
and their meninges, of a peripheral system of nerves which brings the 
former in constant communication with every part of the body, and of 
the sympathetic system of nerves and plexuses which serve the same 
purpose for the internal organs. 

The brain itself consists of two lateral hemispheres and their envelopes, 
an after part which is called the cerebellum, and a basal portion which 
connects it with the spinal cord. Closely surrounding and adhering 
to the surface of the brain is the pia mater, this dipping into the various 
fissures. The other parts of the meninges, that is, the arachnoid and the 
dura, adhere so closely that they cannot be differentiated (Fig. 42) . 

The substance of the brain itself consists of a cortex averaging about 
one-quarter inch in thickness, in which are situated a series of layers of 
nerve cells. From these nerve cells arise numerous fibers which go to 
other parts of the brain and into the spinal cord. That part of the 
nervous system which consists of nerve cells is always grayish in appear- 
ance, and that which is composed of nerve fibers is of white color. Be- 
sides the accumulation of nerve cells which is found in the periphery 
of the brain tissue, that is, the cortex, there are other collections of 
nerve cells, or ganglia, which are situated within the hemispheres. These 
ganglia are called the corpora striata, and consist of the caudate nucleus, 
the lenticular nucleus, and the optic thalamus. 

The convolutions and fissures which make up the surface of the brain 
underneath which the cortex lies have a definite and systematic arrange- 
ment, this being apparently in accordance with the importance of the 
functions concerned. Thus, embryologically one of the first fissures to 
be marked is the Sylvian fissure, around this being the important motor 
and sensory centres, and the nerve fibers which are in relation with these 
functions are the first to develop or obtain their myelin sheaths (Fig. 43). 



Fig. 42 



End of calloso- 
marginal fissun 




Ascendlmj fissure ; \ 
of Sylvius. / \ 
Fissure 
of Sylvius. 



Conv^olutions and sulci on the exteral surface of the cerebral hemisphere. (Gray.) 

Fig. 43 




Convolutions and sulci on the internal surface of the cerebral hemispheres. (Gray.) 



142 DISEASES OF THE NERVOUS SYSTEM 

Cortical Localization. — As a result of embryological, histological, 
experimental, and pathological studies, different functions have been 
assigned to different parts of the cortex. 

Motor Centres. — ^The motor functions have been placed directly in 
front of the central, or Rolandic, fissure in the precentral convolution on 
the lateral surface of the brain and in the anterior part of the paracentral 
convolution in the median portion. Every movement has its cortical 
representation, the head centre being in the lowest part of the precentral 
convolution, then the centres for the face, arm, trunk, abdomen, and leg 
coming in order, that for the leg being highest. Thus a man stands 
upside down in his motor cortex. Should there be any lesion such as 
would irritate any of these centres, for instance a tumor in the arm area 
on the right side of the brain, there would result convulsive movements 
of the left upper limb. Should this lesion destroy this centre, paralysis 
of the limb would result. It must be remembered that while the centres 
concerned in the innervation of structures necessary for a movement are 
somewhat distinct, there cannot be and there is not a definite division, 
and that the nerve cells related to different functions are in apposition 
and intermingle. Thus it is that irritation of the arm area by an electric 
current or by a tumor, while it will cause a convulsion of an upper limb, 
might also cause movements of the lower limb. 

Sensory Centres. — Directly back of the motor centres, behind the central 
fissure, are located the sensory functions. In this area are included not 
only the postcentral, but also the superior and inferior parietal convolu- 
tions. In the postcentral convolution itself are placed the centres for 
touch, pain, and temperature, that is, those sensations which are primary 
and which develop first. Their localization is similar and in apposition 
to that of the motor functions; that is, those which are concerned in the 
innervation of the head are below, and of the leg above. In the parietal 
convolution have been placed the centres for the so-called acquired 
sensations; that is, the senses of pressure, movement, position, localiza- 
tion, and stereognosis, or the ability to recognize objects placed in the 
hand. In the inferior parietal convolution the above sensations are 
localized for the upper limb and in the superior parietal convolution for 
the lower limb. Should there be any irritative lesion, for instance, in the 
centre for sensation in the upper limb on the right side of the brain, there 
will be numbness and pain localized in the left upper limb, these sensa- 
tions being analogous to the convulsive movements which result from 
irritative phenomena of the motor centres. Destruction of any sensory 
centre will also in a similar way produce loss of sensation or anesthesia 
(Fig. 44). 

Motor Aphasia. — In the posterior portion of the third, or inferior, frontal 
convolution is Broca's convolution, that is, the gyrus which surrounds the 
end of the ascending limb of the fissure of Sylvius. This convolution is 
adjacent to and in front of the head and face centre, and is the part of the 
brain which controls motor speech. Should there be a disturbance of 
this centre, the patient would know what he wanted to say, would under- 
stand everything said to him, but would not be able to talk or repeat 



PHYSIOLOGICAL ANATOMY 



143 



words : not because of any paralysis of the muscles which are concerned 
in speech, but because of destruction of the coordinating centre which 
controls these muscles. This is motor aphasia. 



Fig. 44 




CONCRLTE CONCEPT 

Side view of human brain, showing localization of functions. (Charles K. Mills.) 



Fig. 45 




View of the mesial surface of the human brain, showing localization of functions. 
(Charles K. Mills.) 



144 DISEASES OF THE NERVOUS SYSTEM 

As most of us are right-handed, the speech centre is locahzed mostly 
in the left cortex. In left-handed persons, however, the speech centre 
is on the right side of the brain. Another important point must be 
remembered, that is, what act controls the right- or left-hand edness of 
the individual. Given a person who is equally skilful with either hand, 
but who writes with the right hand, such a person will be preponderantly 
left-brained. In other words, the function of writing, which is perhaps 
the highest of the developmental functions, controls largely the side on 
which the speech centre is principally localized (Fig. 45). 

Sensory Aphasia. — In the middle portion of the left first and second 
temporal convolutions in right-handed persons is the centre for sensory 
speech. A lesion of this part will cause loss of memory for words and their 
meaning. Such a person would be unable to understand what is said 
to him, and he would be able to talk, because his motor apparatus is 
intact. His words, however, would be unintelligible and devoid of meaning. 

Word and Letter Blindness. — Around the end of the first temporal 
convolution is what is called the angular gyrus. This convolution is 
directly back of the inferior parietal, or sensory, convolution and between 
it and the visual or occipital centres. In right-handed persons this centre 
controls the ability to recognize words, letters, and figures. In a destruc- 
tion of this area the patient will be unable to write his name, or, in fact, 
to write anything or to read words, letters, or figures, or to write from 
dictation. He would, however, be able to recognize other objects, as 
pictures or music, or he would be able to sketch or draw or recall from 
memory any object in which words, letters, or figures are not concerned. 
This is called word, letter, or figure blindness. 

Visual Centres. — ^The centres for vision are localized in the occipital 
convolutions, especially around the part surrounding the calcarine fissure 
or the cuneal lobe. The parts around the calcarine fissure are concerned 
with direct vision, while the other portions of the occipital cortex control 
peripheral vision. Should there be a lesion, for instance, of the right 
calcarine fissure, there would be loss of direct vision in the left half of 
each central visual field. In a lesion of the occipital lobe of the right 
side there will result blindness of the left half of each visual field, that is, 
left lateral homonymous hemianopsia, because the right occipital lobe 
supplies the right half of each retina, this controlling the left field of vision. 
In an irritative lesion of these parts there will result flashes of light in 
the corresponding fields. 

Psychical Centres. — ^The higher psychical functions have been placed 
in the frontal lobes, and especially in the left. In any lesion of these 
lobes there will result failure of memory, loss of intelligence and of 
reasoning, change of disposition and of character. It must be remem- 
bered, however, that there is no definite mental phenomenon associated 
with a lesion of the frontal lobes, and failure of intelligence is not diag- 
nostic of such lesion, for a lesion in any portion of the brain must cause 
some loss of intelligence, for every portion of the cortex is in constant 
communication with every other, and a destruction of one part must cause 
a disturbance of the integral whole. 



PHYSIOLOGICAL ANATOMY 145 

Subcortical Centres. — Generally speaking, the symptoms of a tumor 
or a lesion localized underneath the cortex will depend entirely upon 
what fibers are cut off. As any lesion will interfere with the fibers 
related to more than one function, the symptoms will never be clean cut. 
For instance, a tumor localized underneath the precentral convolution 
will not only give motor symptoms, but will also give some involvement 
of sensation. 

While it is acknowledged that in the cortex are localized the centres for 
every motion, sensation, and special act, it must be remembered that 
this is so only so far as simple acts like lifting a finger or moving a limb 
are concerned. Where, for instance, it is necessary to perform a complex 
act, such as talking, laughing, crying, eating, or swallowing, there must 
be some one place or centre which coordinates the different functions 
which such an act must comprise. The speech centres, probably 
because of their importance, are largely localized in the cortex, but they 
also have representation in the subcortex. As to where the centres for 
laughing, crying, eating, and swallowing are we are not certain, but we 
believe that they must be localized in some of the ganglia in the subcortex, 
among these the optic thalamus and the lenticular and the caudate 
nucleus probably playing the most important role. 

Internal Capsule. — ^The internal capsule is the name given to the 
pathway of fibers which come from the cortex. It contains an anterior 
limb, a knee, and a posterior limb. The anterior limb transmits the 
fibers coming from the frontal to the opposing cerebellar lobe, the so- 
called frontocerebellar fibers. The knee of the internal capsule trans- 
mits those fibers which come from the lowest portion of the precentral 
convolution, i. e., the head and face centres, these being the fibers 
which go to the nuclei of the cranial nerves situated in the crus, 
pons, and medulla, i. e., from the third to the twelfth nerves inclusive 

The posterior limb of the internal capsule transmits in its anterior 
portion the motor fibers, in its middle the sensory, and in its posterior 
portion the fibers which come from the occipital or visual lobes. Should 
there be a lesion of the posterior limb of the internal capsule, as, for in- 
stance, a hemorrhage, there would result hemiplegia, hemianesthesia, and 
hemianopsia on the other side. This is the only place in the brain 
where one lesion will always give these three symptoms. 

The Crus, or Cerebral Peduncles.— The cerebral peduncles are 
practically the continuations of the posterior limbs of the internal capsule 
and transmit the fibers for motion and sensation, thus connecting the 
brain proper with the brain stem. 

The nucleus of every cranial nerve from the third to the twelfth inclu- 
sive receives its innervation from the opposite cortical centre. The 
first and second cranial nerves do not enter into this, as they are really 
parts of the brain. 

The nucleus of the third, or the oculomotor, nerve is situated in the 
posterior portion of the crus, and its fibers have their exit at the foot of 
the cerebral peduncles. A unilateral lesion, therefore, of the cerebral 
10 



14G 



DISEASES OF THE NERVOUS SYSTEM 



Fig. 46 



Hypogl 




Horizontal section through the right hemisphere. B. Kn, knee of corpus callosum; Vh, anterior 
liorn of lateral ventricle; F^, inferior part of third frontal convolution; I. stric, lenticulo-striate 
division of internal capsule; Knie. ic.,knee of internal capsule; I. optic, lenticulo-optic division of 
internal capsule; Th, optic thalamus; /, island of Reil; cl, claustrum; Operc, operculum; T^, first 
temporal convolution; r. lie, retrolenticular region of internal capsule; C. A., hippocampus major; 
calc, calcarine fissure; Hh, posterior horn of lateral ventricle; SS, optic radiation of Gratiolet; Tg, 
second temporal convolution; Facialis, position in capsule of motor tract to the face; Hypoglossus, 
position of tract to the tongue; Arm, position of tract to the arm; Bein, position of tract to the leg; 
S. B., sensory fibres; S, visual tract; A, auditory tract. (M. Allen Starr, after von Monakow.) 



PHYSIOLOGICAL ANATOMY 147 

peduncle would always give oculomotor palsy on the same side with the 
addition of a paralysis of the lower part of the face, arm, and leg on the 
other side of the body. 

The Pons. — In the pons are located the nuclei for the fifth, sixth, 
seventh, and part of that of the eighth cranial nerve, the exits of these 
nerves corresponding in order. In a unilateral lesion of the upper part 
of the pons there will be paralysis of the fifth nerve on the same side with 
hemiplegia of the opposite side. In a lesion limited to the lower portion 
of the pons, there will result facial palsy on the same side and paralysis of 
the arm and leg only on the other side. In discussing the symptoms 
of lesions in the crus and pons, it has been assumed that these are 
confined to the anterior portions of these structures. Should the lesion, 
however, be more extensive, there would necessarily have to be involve- 
ment of the sensory fibres which are localized directly back of the motor, 
and there would result in addition sensory symptoms on the other side. 

Paralysis of Associated Ocular Movement. — Should, however, the 
lesions involve the median portions of the crus and pons, there would be 
paralysis of associated ocular movement. This is rather difficult to 
understand, unless it is remembered that it is impossible to move one eye 
without the other, and therefore every movement of the eyeballs must be 
an associated movement. When we look to the right we use not only 
the external rectus muscle on the right side, but we also use the left 
internal rectus, i. e., we are receiving innervation from the nuclei of the 
sixth and third cranial nerves. To make this possible there must be a 
connection between these nuclei, and this is accomplished by means of 
the posterior longitudinal bundle w^hich is located in the posterior and 
median portion of the crus and pons. 

In looking downward we use not only the muscles which are innervated 
by the third, but also those which are innervated by both fourth cranial 
nerves. In looking upward we use only the muscles which receive 
innervation from both oculomotor nuclei. We see then that there must 
be a similar connection between the oculomotor nuclei and between 
these and the nuclei of the fourth nerves. 

Should there be a lesion, for instance, in the lower part of the right 
side of the pons, cutting oft' the posterior longitudinal bundle, there will 
be inability to look to the right, and a similar lesion on the left side 
will cause inability to look to the left. A lesion cutting off both bundles 
will cause inability to look to the right or left, but the ability to look 
upward and downward will be retained. 

In a lesion of the upper portion of the pons which cuts off the connec- 
tion between the third and fourth nuclei there w^ill be paralysis of asso- 
ciated movement downward. A lesion still higher up will cause failure 
of upward movement. 

Partial or Total Lesions of the Medulla Oblongata.— Partial or 
total lesions of the medulla oblongata will not be considered, because 
liemorrhages nearly always prove immediately fatal. Neither will 
lesions of the quadrigeminal and other structures, because of our lack 
of definite knowledge. 



148 DISEASES OF THE NERVOUS SYSTEM 

The Cerebellum. — ^The cerebellum consists of a middle portion, or 
the vermis, and two lateral lobes. It is connected with the rest of the 
brain by three processes called the cerebellar peduncles, the superior or 
first connecting it with the brain proper, the middle with the pons, and 
the inferior with the medulla and spinal cord. In the middle lobe are 
situated the dentate nucleus, the nucleus fastigii, and the nucleus emboli- 
formis and globosus. In addition certain nuclei situated in the medulla 
oblongata are in direct communication with the cerebellum, and should 
be regarded really as part of it. These include Deiter's nucleus, the 
nucleus vestibularis, and the nucleus magnocellularis substantia reticu- 
laris, these being called altogether the paracerebellar nuclei. 

The functions of the cerebellum are not definitely known. Experi- 
mental and clinical evidence seems to show that lesions in any portion 
will produce symptoms of incoordination of a definite character. It 
has recently been demonstrated by Sir Victor Horsley that the cortex of 
the cerebellum is inexcitable, but that irritation of the intrinsic cere- 
bellar nuclei will produce conjugate deviation of the eyes and head to 
the same side, besides flexion of the homolateral elbow, and that deeper 
excitation of the paracerebellar region will produce extension of the 
contralateral elbow, hyperextension of the neck and trunk, with powerful 
extension of the lower limbs. 

It is probable that the cerebellum is concerned with the coordination 
of every voluntary movement, whether this be of the limbs, eyes, or of 
those muscles which are concerned in articulation, eating, or swallowing. 
It is characteristic of this incoordination that it is apparent only in volun- 
tary movements and that it does not increase when the object is attained 
or when the eyes are shut and that it is not dependent upon any dis- 
turbance of peripheral sensation. 

It has also recently been held that lesions of the cerebellum will pro- 
duce weakness or paresis of the muscles of the trunk and limbs, but 
this is not a true weakness in the sense that it is dependent upon the 
motor fibers. Besides, there may be present in the muscles a lack of 
tone, so that the limbs would be moved like a flail. If the lesion is in 
the middle lobe, or the vermis, the symptoms of incoordination are most 
marked and will involve both parts of the body, while unilateral lesions 
will, of course, produce preponderant unilateral ataxia and atonia. 

Whatever symptoms are produced by lesions of the cerebellum or by 
those lesions which invade the cerebellum by pressure are dependent 
upon this disturbance of coordination. This is apparent in every move- 
ment, whether it be in the gait, station, in the movement of a limb or 
limbs, or of the eyes, or of those muscles which are concerned in eating, 
talking, and swallowing. Other localizing symptoms will be discussed 
under the head of cerebellar tumors. 

The Cranial Nerves (Fig. 47). — ^There are twelve pairs of cranial 
nerves. These are known either by special names or numerically. The 
first and second, or the olfactory and the optic, nerve should really be 
considered as parts of the brain proper and not as distinct cranial nerves. 

The centre for the olfactory nerve is not definitely known, but its func- 



PHYSIOLOGICAL ANATOMY 



149 



tion is concerned with smell, the loss of which is very frequent in fracture 
of the base of the skull. 

The ojptic, or second, nerve is the nerve of vision. From the orbits, in 
their course backward, the optic nerves enter into and form the optic 
chiasm and then the optic tract, and from here the visual fibers go to the 
primary optic centres, these constituting the anterior corpora quadri- 
gemina, the external geniculate body, and the pulvinar, or posterior, 
portion of the optic thalamus. Thence the fibers pass through the 
extreme posterior portion of the posterior limb of the internal capsule 
to -the occipital lobe. 

Fig. 47 



OLFACTORY 
BULB 

_ GENU OF 
CALLOSUM 




SYLVIAN 
FISSURE 

anterior per- 
■"forated space 

NFUNDI- 
BULUM 



posterior per- 
forated SPACE 
.CRUS CEREBRI 



MIDDLE CEREBEL- 
LAR PEDUNCLE 



OBT.ONGATA 



CEREBELLUM 



Under surface of the brain, showing the superficial origins of the cranial nerves. The Roman 
numerals indicate the nerves. (Testut.) 

It must be remembered that the visual fibers coming, for instance, 
from the right occipital lobe innervate the right half of each retina and 
thereby supply vision to the left half of each visual field. A lesion 
interrupting the fibers coming from the right visual centres or the 
occipital lobe, for instance either in the extreme posterior portion of the 
posterior limb of the internal capsule or in the so-called primary optic 



150 



DISEASES OF THE NERVOUS SYSTEM 



centres or in the optic tract, must give loss of half vision in both visual 
fields on the other side, or left lateral homonymous hemianopsia. From 



Fig. 48 



yisucd 




''''^'^Zobe 



The visual tract. 'The result of a lesion anywhere between the optic chiasm and the cuneus is to 
produce homonymous hemianopsia. H, lesion at chiasm causing bilateral temporal hemianopsia; 
iV, lesion at chiasm causing unilateral nasal hemianopsia; T, lesion at chiasm causing imilateral 
temporal hemianopsia; aSA", substantia nigra of crus; L, lemniscus in crus; RN, red nucleus; ///, 
third nerves. 

each optic tract a part of the visual fibers innervate the temporal part of 
the retina on the same side and the nasal of the other. The decussation 



PHYSIOLOGICAL ANATOMY 151 

of the nasal fibers takes place in the centre of the optic chiasm. A lesion, 
therefore, of the middle of the optic chiasm will give loss of innervation 
to the nasal part of each retina or bitemporal hemianopsia. 

A lesion interrupting the fibers on the outer side of the optic chiasm, 
as for instance the right, will cause loss of innervation to the right tem- 
poral retina, and therefore loss of the nasal field of vision of the right eye. 
A bilateral lesion must give bilateral loss of vision of the nasal fields, or 
binasal hemianopsia (Fig. 48). 

A lesion destroying the whole optic chiasm, as, for instance, a tumor 
of the hypophysis, will cause loss of vision in both eyes. Destruction of 
either optic nerve will necessarily give blindness in the corresponding eye. 

Choked Disk, or Optic Neuritis. — Whenever there occurs increase of 
intracranial pressure, whether because of a brain tumor, trauma, or 
internal hydrocephalus, pressure will be exerted upon the optic chiasm 
and optic nerves. This is because pressure in any portion of the brain 
will result in a heightened tension in the lateral and the third ventricle, 
the latter pressing directly upon the optic chiasm and optic nerves. 

In every choked disk there must be some inflammation of the optic 
nerve, or optic neuritis, but in optic neuritis choked disk does not neces- 
sarily occur, for the latter is distinctly a pressure symptom. When the 
optic nerve is pressed upon there will be first a stasis of the vessels, this 
resulting in a swelling of the veins which is so severe at times as to pro- 
duce hemorrhages. There will also be retardation of the arterial flow 
causing a diminution in the size of the arteries. Because of this stasis 
there will result an edema, which will produce a swelling of the optic 
nerve fibers or of the optic nerve head. If the pressure is continued the 
nerve fibers will become diseased, resulting in impairment of vision. This 
is choked disk. If the pressure is continued for a long time there will 
necessarily result atrophy of the optic nerve fibers. 

Pupils. — ^The ciliary muscles react to two forms of stimulus : (1) light, 
and (2) movement of the eyeballs. No matter what the stimulation, 
the contraction or dilatation of the pupil is performed by the same ciliary 
muscle, but the innervation differs. The ordinary light stimulation is 
transmitted by means of the optic nerve to the oculomotor nucleus, and 
from here the impulse to the ciliary muscle is carried by the oculomotor 
nerve. This is the light reflex arc, and, if there is any disturbance any- 
where in the arc, there will be impairment or loss of the reaction of the 
pupil to light. The fibers which are concerned with the reaction of the 
pupil to movement, as, for instance, in convergence and divergence and 
in upward, downward, and outward movements, have probably a similar 
arc, with the addition that they are in connection with the nuclei of the 
muscles necessary to perform the given ocular movement. 

There is no subject of which we have a less definite knowledge than 
this, and it is a safe rule when considering symptoms of brain lesion to 
pay no attention whatever to the condition of the pupils. 

The oculomotor, or third, nerve supplies the orbicularis palpebrarum 
and all the muscles of the eyeball with the exception of the superior 
oblique and the external rectus. A total paralysis of this nerve will 



152 DISEASES OF THE NERVOUS SYSTEM 

cause ptosis of the upper lid, outward deviation of the eye, and enlarged 
pupil, with inability to move the eye in any but the outward direction. It 
is possible to have a partial involvement of the oculomotor nerve. A total 
or partial oculomotor palsy is nearly always indicative of basal syphilis. 

Paralysis of the trochlear, or fourth, nerve is an extremely rare condition 
and hardly ever occurs alone, but is generally found in association with 
palsies of the other ocular muscles. This nerve supplies the superior 
oblique muscle which rotates the eye downward and outward. Basal 
syphilis is nearly always the cause of the paralysis. 

The trigeminus, or fifth, nerve has both a sensory and a motor function, 
but is mostly sensory. The motor part supplies the muscles of mastica- 
tion. The sensory division supplies sensation for the face, eye, nose, jaws, 
teeth, palate, and pharynx, and also the anterior two-thirds of the tongue. 

In paralysis of the motor fifth there will be inability to chew on the side 
of the paralysis, the contraction of the masseter muscle will be weak, and 
the jaw will deviate toward the affected side. In an irritating lesion of 
the sensory part of the fifth nerve there will be pain either in its whole 
distribution or in a subdivision of the nerve, i. e., the supra-orbital, 
infra-orbital or mental. If the nerve is cut, or if the lesion is destructive, 
there will be anesthesia in the related parts. 

The abducens, or sixth, nerve supplies the external rectus muscle, which 
pulls the eye outward. Temporary or permanent paralysis is a very 
frequent and early symptom in basal syphilis and in brain tumors. 

The facial, or seventh, nerve supplies the muscles of the face, including 
the buccinator. Paralysis causes inability to elevate the brow, shut the 
eye, or elevate the corner of the mouth on the involved side, with the 
addition of lacrymation in the involved eye. Palsy occurs in basal 
syphilis, but not so commonly as in the sixth nerve. 

The auditory, or eighth, nerve has two divisions, the cochlear, which 
is the nerve of hearing, and the vestibular, which is concerned with 
coordination. Basal syphilis or tumors are the most frequent cause of 
unilateral deafness. 

Meniere's disease is the name given to a symptom-complex which 
generally occurs in the latter end of life, and, as a rule, begins with 
unilateral noises in the ear, accompanied by some dizziness. These 
first come on at intervals; gradually the tinnitus increases, the noises 
sometimes resembling the shrieking of a whistle, becomes bilateral 
and is accompanied by excessive vertigo, which, as a rule, terminates 
in nausea and vomiting. There is progressive loss of hearing. The 
tinnitus, vertigo, and deafness become constant, sometimes preventing 
the patient from assuming an erect posture. Rarely, when the deaf- 
ness becomes complete, the vertigo and tinnitus cease. It is supposed 
that this symptom-complex is due to a disease of the terminal filaments 
of the vestibular nerve in the labyrinth, and there may also be disease 
of the semicircular canals. 

The glossopharyngeal, or ninth, nerve supplies sensation for the pos- 
terior third of the tongue and the pharynx, and also motion for some 
of the palatal and pharyngeal muscles. 



DISEASES OF THE BRAIN AND ITS MENINGES 153 

The pieumogcLstric, or tenth, nerve supplies the heart, lungs, abdominal 
viscera, and the pharyngeal and laryngeal muscles. 

The spinal accessory, or eleventh, nerve besides innervating the trape- 
zius muscle helps to innervate the same structures that the tenth nerve 
does. Isolated paralysis of any of the above three nerves is most 
unusual. 

The hypoglossal, or twelfth, nerve supplies motion to the tongue. In 
cases of paralysis the tongue will be protruded to the corresponding 
side and, when in the mouth, will deviate to the opposite side. Isolated 
lesions are very uncommon. 



DISEASES OF THE BRAIN AND ITS MENINGES. 

Certain general symptoms may be present in any disease of the brain 
or its meninges, the degree and number of these depending upon the 
nature, extent, and location of the lesion. They are headache, nausea, 
vomiting, vertigo or dizziness, disturbances in motility, such as tremors, 
convulsions, general or focal in type, partial or total paralysis, disorders 
of sensation and disturbances of vision or of the other special senses, 
and lastly alterations in mentality. 

Headache. — Headache as a result of any cerebral lesion is nearly al- 
ways due either to an irritation of the dura or an increase of intracranial 
pressure which causes tension of the dura. The meninges are inner- 
vated by the sensory portion of the fifth nerve, hence, diseases of this 
must cause pain. At times the headache is localized to the place 
of direct irritation, but, as a rule, it is general. The pain is usually 
severe and constant and is difficult to relieve by medication, and vomit- 
ing does not lessen its intensity. 

Nausea and Vomiting. — The nausea and vomiting which are present in 
diseases of the brain are generally indicative of intracranial pressure, for 
they are not present unless such be the case. They are probably due to 
an irritation of the ninth and tenth nerves. The nausea may appear in the 
morning or at any time and may be accompanied by vomiting, but the 
latter, as a rule, does not relieve the nausea or the accompanying headache. 
The vomiting is generally projectile in character and comes on without 
warning. These symptoms are generally indicative of brain tumor. A 
greater amount of nausea and vomiting is present in cerebellar lesions 
because pressure is more direct upon the ninth and tenth nerves. 

Vertigo, or Dizziness. — Vertigo, or dizziness, is also considered a pressure 
symptom in diseases of the brain. The dizziness may be objective or 
subjective, i. e., the patient may either see objects move before him or he 
may have a sensation that he moves himself. In cerebral tumors this 
symptom is not very common, but in cerebellar lesions vertigo appears 
early and is marked and persistent. It is probably due to pressure 
which is exerted on the vestibular division of the eighth nerve. 

Disturbances in motility do not occur unless there is an involvement 
either of the cortical motor centres or of the fibers coming from them. 



154 DISEASES OF THE NERVOUS SYSTEM 

Because of the readiness with which motor symptoms are detected, they 
are more quickly appreciated than other symptoms. They may consist 
of tremors, forced movements, convulsions, either general or focal, and 
partial or total paralysis. 

Tremors. — ^These may be coarse or fine. Coarse tremors do not 
result from surgical brain lesions, and are usually indicative of paralysis 
agitans, multiple sclerosis, or of some functional disturbance. Under 
fine tremors we may consider fibrillary twitchings. These are always 
indicative of a slow and progressive degeneration of nuclear cells. 

Forced Movements. — Under this will be discussed athetosis or athe- 
toid movements. These may be present in the face or in all of the limbs, 
or in any one of the limbs or face, and are always indicative of a lesion 
of the motor columns either at infancy or birth. The athetoid move- 
ment is slow, twisting, and constant. 

Convulsions. — These are characterized by spasmodic movements of a 
part of a limb, a whole limb, one-half of the body, or of the whole body, 
and may be accompanied by loss or impairment of consciousness. If the 
convulsive movement is limited to a part of a limb, or a limb, or one-half 
of the body, and if it begins always in the same muscles, it is called a 
focal, or Jacksouian, convulsion, and is nearly always indicative of an 
irritative lesion in the motor cortex. In Jacksonian convulsions, or 
epilepsy, the spasms come on quickly and may last from a few seconds 
to several minutes, are generally clonic in type, and, as a rule, are not 
accompanied by unconsciousness. 

It is of the utmost importance to see where a Jacksonian convulsion 
begins, what muscles or movements it involves, and their succession. 
Supposing, for instance, twitchings began in the fingers of the right hand, 
and from here the movement extended into the muscles of the forearm, 
arm, and shoulder, and then into the muscles of the face. This would be 
indicative of a lesion in the left motor cortex, probably extending from 
the hand to the face centre, i. e., from the middle to the lower portion of 
the precentral convolution. Should, however, the convulsion involve the 
leg instead of the face, it would indicate that the lesion extends from 
the middle of the precentral convolution upward or to the leg centre. 
These facts are of the utmost importance when surgical procedures are 
considered, for upon their correct observation will rest the selection of 
the seat of operation. 

Epilepsy. — General convulsions are nearly always indicative of epilepsy. 
This disease is probably due to maldevelopment of the brain, and the 
spasms in the large majority of cases first appear in infancy. Only rarely 
do they appear after the. twentieth year. One of the frequent causes 
is injury to the head very early in life, and less frequently does it follow 
injury to the head in adults. The cardinal symptom of epilepsy is loss 
of consciousness. 

There are three types of attacks : First, major epilepsy, or grand mal; 
second, minor epilepsy, or petit mal; and third, psychic epilepsy. 

In major epilepsy, or grand mal, there may or may not be an aura. 
This may be either a feeling of numbness which ascends from the fingers 



DISEASES OF THE BRAIN AND ITS MENINGES 155 

to the shoulder, or starts from the stomach and goes to the neck. An 
am'a may consist in disturbances of any of the special senses, or the 
patient may have a feeling that something is going to happen. This 
aura may last a second, a few seconds, or a minute or longer, and is 
followed, as a rule, by a cry, the so-called epileptic cry, and the patient 
falls to the ground unconscious. The body then becomes rigid, the 
head may bend backward, the hands are clinched, the face is blue or 
livid, the eyes may roll in any direction, and the teeth are clinched. 
Generally the patient bites his tongue and froths at the mouth. This 
tonic condition may last from a few seconds to several minutes, and is 
succeeded by clonic or intermittent movements which may last also from 
a second to several minutes. Relaxation then follows, and the patient 
may rally from the attack immediately or may not do so for several hours 
or longer. The patient generally feels weak and exhausted afterward. 
Because of the contraction of the abdominal muscles on the bladder 
walls there is usually some dribbling of urine. 

The above description is that of a typical attack of major epilepsy. 
There are, of course, variations of this, some attacks being more severe 
than others. As a rule, these convulsions occur intermittently, some- 
times daily or oftener, or every week or month ; but if a number of attacks 
come on one after another the condition is known as status epilepticus. 

By minor epilepsy, or petit mal, is meant a condition in which the patient 
has only very small movements, which may consist of the twitching of 
an eyelid or movement of an eye, or movements of the jaw or tongue or 
of any of the limbs; but the important point is that there is always 
momentary loss of consciousness. 

By psychic epilepsy is meant a condition in which there is loss of 
consciousness, but in which no movements occur. There are of course 
variations of this, and there may be conditions in which the patient is in a 
semistuporous or somnambulistic condition, and performs automatic 
movements or does reasonable things, after w^hich there is no recol- 
lection of what has happend. As a rule, however, these attacks last 
only a few seconds. In association with this there are always attacks 
of grand mal or petit mal. 

Partial or Total Paralysis. — It must be borne in mind that in the motor 
cortex are represented the centres for movement, and, if these are destroyed, 
paralysis of movement will occur, the extent and completeness depend- 
ing upon the centres destroyed. Paralysis of one limb, the result of a 
cortical lesion, is very unusual, and, if present, is always due to a small 
tumor or more probably an injury. If the whole motor cortex is destroyed, 
hemiplegia will result. 

Reflexes. — ^E very reflex has its physiological arc, this consisting of a sen- 
sory impression, a centre, and a motor response. The simplest example 
is the knee, or patellar, jerk, in which, after tapping the patellar tendon, 
the impulse is carried by the sensory nerves and posterior roots to the cells 
of the anterior horn in the second, third, and fourth lumbar segments, 
and from here the motor response is transmitted by the anterior roots 
and the peripheral motor nerves. If there is a lesion in any portion of 



156 DISEASES OF THE NERVOUS SYSTEM 

this arc, there will be loss of the reflex, no matter what the condition above 
in the spinal cord and brain. The first principle then in the attainment 
of any reflex is to have its arc intact and in normal condition. Should, 
however, there be a lesion in any portion of the upper motor neuron or 
system anywhere in its course, and the relation of tone is disturbed, there 
will result exaggeration of the reflexes because of loss of cerebral, or what 
has often been called inhibitory, influence. That every reflex has a cerebral 
influence is proved by the fact that if there is a complete transverse lesion, 
for instance in one segment of the cervical cord, all the reflexes below are 
lost even though the arcs are intact. 

Reflexes are of two kinds: First, deep, or tendon, and second, super- 
ficial, or skin. The usual tendon reflexes elicited are: 
/ (a) In the upper limb : The biceps and triceps. 

The biceps reflex is obtained by having the patient flex the forearm on 
the arm at a right angle. The thumb of one hand of the examiner is 
then placed on the biceps tendon. Striking the thumb with the per- 
cussion hammer will produce flexion of the forearm upon the arm. 
The centre of the reflex is in the fifth cervical segment. 

Triceps Reflex. — With the arm in the same position, if the triceps 
tendon is struck near its insertion at the elbow, extension of the forearm 
on the arm will result. The spinal centre is in the sixth and seventh 
cervical segments. 

(h) In the lower limb : 

The knee, or patellar, jerk is best obtained by crossing one leg over the 
other and striking its patellar tendon near its insertion. A forward 
movement of the leg will result. The spinal centre is in the second, third, 
and fourth lumbar. When the reflex is diminished it may sometimes be 
brought out by reinforcement. This is done by having the patient lock 
his hands and then pull them apart at a signal, the examiner striking 
the tendon at the time of the greatest effort. 

The Achilles jerk is best obtained by having the patient kneel on a chair 
and then tapping the Achilles tendon near its insertion into the heel. A 
flexion of the foot on the leg will result. The spinal centre is in the 
first sacral. 

Ankle and Patellar Clonus. — A clonus is obtained only when there is 
an exaggerated tonicity, and always indicates a lesion of the motor, or 
pyramidal, tracts. Ankle clonus is obtained by first flexing the leg upon 
the thigh. With one hand held over the calf of the leg, the other holding 
the foot, a sudden flexion of the foot on the leg is made, this resulting 
in to-and-fro movements at the ankle which are regular in rhythm. 
Patellar clonus: With the leg extended on the thigh the patella is grasped 
between the thumb and the forefinger and suddenly brought forward. 
Rhythmical up-and-down movement constitutes patellar clonus. 

Biceps and triceps clonus is sometimes obtained similarly to that of 
the ordinary reflexes. 

Rarely ankle clonus and sometimes patellar clonus can be obtained in 
hysteria, but the movements are not regular and the rhythm is influ- 
enced by the will. 



DISEASES OF THE BRAIN AND ITS MENINGES 



157 



Skin, or Superficial, Reflexes. — The abdominal, or umbilical, reflex is 
obtained by stroking upon one side of the abdomen, the umbilicus 
approaching to the side of the irritation. The spinal centre is in the 
ninth, tenth, and eleventh thoracic segments. 

The cremasteric reflex is obtained by irritating the inner portion of the 
upper thigh, this resulting in upward movement of the scrotum on that 
side. The spinal centre is in the first lumbar segment. 

The plantar reflex is obtained by irritating the plantar surface of the foot, 
flexion of the toes resulting. The spinal centre is in the second sacral. 



Fig. 49 




Contractures following hemiplegia. Birth palsy. Patient has epilepsy. Contractured elbow, 
wrist, and digits. Atrophic (poorly developed) musculature. Left leg similarly but less markedly 
afifected. 



Babinski's reflex is obtained by irritating the plantar surface of the foot, 
extension of the toes resulting Irritation is best produced with a match, 
which should first be carried on the outer part of the foot and then across. 
The important part of this reflex is the slow extension of the large toe; 
the movements of the small toes may be disregarded. It is also advis- 
able to first grasp the foot at the ankle so as to obviate any voluntary 
movement. This reflex is never obtained in a functional condition, and 
is always indicative of a lesion of those motor fibers which are in relation 



158 



DISEASES OF THE NERVOUS SYSTEM 



with the lower Hmb. A lesion of the motor fibers in relation with the 
upper limb will not produce this reflex. 

Hemiplegia. — By hemiplegia is meant paralysis of an arm, leg, and the 
lower part of the face on the same side. Such a patient will be able to 
wrinkle the brow and close the eyelids, but will not be able to elevate 
the corner of the mouth on the paralyzed side. In every hemiplegia 

Fig. 50 




Left hemiplegia, showing drooping of the left side of the face and flexor contractures in the left 
upper limb, differing from the extensor contractures of spinal-cord disease. 



there is always some return of power, and it is a rule that there is a greater 
return in those muscles which are concerned with the most common 
movements. In the upper limbs, the flexors being stronger, there is a 
greater return of power in these muscles, this resulting in a flexor con- 
tracture (Fig. 50). In the lower limbs, the extensors being the stronger, 
the contractures are always in extension. Besides the loss of power. 



DISEASES OF THE BRAIN AND ITS MENINGES 159 

with its subsequent partial return, there is accompanying stiffness, or 
spasticity, with increase of all of the tendon reflexes, ankle clonus, and 
the Babinski reflex. 

"Wlienever there occurs a lesion of the motor system, whether this be 
in the cortical centres or in the motor tracts anywhere in their course, 
either in the brain or spinal cord, there will always be, beside the weak- 
ness consequent upon such a lesion, a spastic condition, or spasticity, 
increase in the tendon reflexes, and the Babinski reflex. 

Hemiplegia may come on as result of lesions at birth, in the infantile 
period, or that period in which the child cannot walk, in the time of 
mature development, or that period between the time when the child is 
fully able to walk to early adult life, about the twenty-first year, and from 
this time on. These subdivisions have been made because the clinical 
type of the paralysis will differ according to the time of life it comes on. 

Hemiplegia Resulting from Injuries at Birth. — ^This occurs only 
when, as a result of difficult instrumental labor, there is an injury to the 
motor cortex either of one or both sides. Pathologically meningeal 
hemorrhages are most frequently found. If the injury is one-sided, a 
hemiplegia will result and the child from its earliest life will be unable 
to use the limbs of one side. The characteristic of this palsy is that the 
paralyzed limbs will never fully develop and will always be smaller than 
those on the healthy side, and there will be present athetoid movements. 
If the meningeal hemorrhage is removed early, it is possible to obtain 
considerable return of power. 

Should there be bilateral meningeal Jiemorrhage there will result a 
paralysis on both sides of the body, or a so-called infantile diplegia. 

In such case there will be bilateral spasticity, increased reflexes, and 
the Babinski reflex. Besides, the limb will never become fully developed 
and there will be present athetoid movements of the upper and lower 
limbs and in the muscles of the face, head, and neck. In most instances 
also there w^ill be inability to talk. 

Paralysis Coming on during the First Two Years of Life, or in the In- 
fantile Period. — To understand this it is necessary to consider the devel- 
opment of the motor system. The child, w^ien it is born, cannot walk 
because of the lack of development of the motor fibers. This can be 
readily seen when a cross-section is made of the spinal cord of a newly 
born child, for the myelin sheaths will not stain. On the contrary, if 
the spinal cord of a chicken, which walks immediately after birth, be 
stained, it will be found that the myelin sheaths are fully developed. 
That is why the chicken can walk and the child cannot. Ordinarily it 
takes from one to two years for the myelin sheaths to obtain full devel- 
opment, and, when this is reached, the child will be able to walk. It can 
be readily seen from this why it is an error to force or urge children to 
walk before they are able to do so themselves, and it also is an evidence 
of the cause of the deformities of such children. Should, therefore, there 
occur a destruction of the motor centres because of an injury, there will 
result a hemiplegia, and, as is the case in paralysis which occurs as a 
result of meningeal lesions, there will be besides spasticity, increased 



160 DISEASES OF THE NERVOUS SYSTEM 

reflexes, the Babinski reflex, lack of development of the limbs; but this 
will not be so great as in lesions at birth. It can also readily be seen 
why a lesion occurring in early infancy will cause a greater lack of 
development. Athetoid movements, as a rule, do not occur, and if the 
lesion should be bilateral it is probable that there will not be much 
impairment of speech. The usual causes of paralysis at this age are 
either injuries or, what is most common, areas of inflammation, or 
encephalitis, resulting from or complicating such infectious diseases as 
scarlet fever, measles, and diphtheria. 

Paralyses which Occur between the Second Year, or the Infantile Period, 
and Full Maturity. — A child grows and does not reach full develop- 
ment until about the twenty-first year, sometimes later. The hemi- 
plegia which occurs in this period will differ from the paralysis occurring 
later only in the fact that there will be a lack of development of the limb, 
this being greater in the early periods of life. The causes are generally 
injury to the head, early syphilis of the nervous system, embolism, or a 
uremic condition. 

The hemiplegias which occur after the twentieth year do not differ as to 
type, but they do as regards their etiology. It is a safe rule to assume 
that when hemiplegia occurs in early adult life, before the forty-fifth year, 
the cause is syphilis. The other causes may be embolism, uremic con- 
ditions, brain tumors, or injury to the head. If the cause is syphilis, 
there may or may not be present other indications or early history of 
such disease. 

Hemiplegias coming on after the fortieth year are usually the result 
of apoplexy. The other causes are also operable. 

Apoplexy. — By apoplexy is meant the bursting of a bloodvessel, the 
usual seat of hemorrhage being in the lenticulostriate artery. A hemor- 
rhage in this portion will usually injure the posterior limb of the internal 
capsule, thereby giving hemiplegia on the opposite side; and if the sensory 
and visual fibers are also involved, hemianesthesia and hemianopsia 
(Fig. 51). Hemorrhages in the other portions of the brain and brain 
stem will give various symptoms according to their localization. (See 
chapter on Cerebral Localization.) 

When apoplexy occurs, there is usually an accompanying shock, the 
patient being rendered unconscious. It is somewhat difficult to tell 
which side is paralyzed, because in the period directly after the attack 
there is so much shock that there is complete loss of tone in all of the 
limbs, and it will be impossible to recognize by the resistance which 
is paralyzed. Later on, of course, tonicity will become apparent in the 
sound side. It will be found, however, that on the side of the paralysis 
there will be drooping of the lower part of the mouth, dribbling of saliva, 
and stertorous respiration. The paralytic will bring to aid all of the 
accessory muscles of respiration and in expiration the cheek on the para- 
lyzed side will be puffed out, and because of this there will be dribbling 
of saliva from the paralyzed to the healthy side. This is an important 
sign. Again, if the patient is stuck with a pin, there will be reflex move- 
ment on the sound side, but not on the paralyzed side. 



DISEASES OF THE BRAIN AND ITS MENINGES 



161 



As a rule, the patient will regain consciousness within a few hours, 
and from then on there will be a progressive return of power, as indicated 
previously. If, however, the patient does not regain consciousness within 
twelve hours, the prognosis is almost invariably fatal. 

When hemiplegia is due to embolism, there is always an accompanying 
heart disease and the signs of a valvular lesion. The onset is generally 
abrupt, and unconsciousness is nearly always present. It may come on 
at any age, but generally in the young. 



Fig. 51 




Hemorrhage into posterior limb of internal capsule and optic thalamus causing hemiplegia, 
hemianesthesia, and hemianopsia on the opposite side. 



Hemiplegia due to thrombosis nearly always has a slow onset and occurs 
after the fortieth year. There is hardly ever unconsciousness. 

When hemiplegia is the result of syphilis, the onset is usually abrupt 
and, as a rule, there is unconsciousness. It generally occurs in persons 
before the fortieth year. 

In the course of a uremic condition it is possible to have paralysis of 

one side of the body. It is characteristic, however, of this disease 

that the paralysis is never complete, that it does not last, and that it is 

always accompanied by convulsions, which may be either Jacksonian 

11 



162 DISEASES OF THE NERVOUS SYSTEM 

or general in type. There are also present the accompanying symptoms 
of uremia, such as unconsciousness, urinous odor, dropsical condition of 
the limbs, and albumin and casts in the urine. 

The paralyses which come on in the course of an injury to the head 
are usually accompanied by the surgical symptoms of the injury. This 
subject will be discussed separately, as will also paralyses resulting from 
brain tumor. In the latter condition the hemiplegia comes on very 
gradually, and there are always the accompanying symptoms of an 
irritative lesion of the brain. 

Disturbances in Sensation. — Disturbances in sensation occurring in the 
course of brain disease are always indicative either of a lesion in the 
sensory cortical centres or in their related fibers. The various forms 
of sensation are : touch, pain, temperature sensation, this including heat 
and cold, bone sensation, and the senses of localization, of movement, of 
position, of pressure, the last four composing what is known as muscle 
sense. The ability to recognize objects placed in the hand is known 
as stereognosis, while the inability to recognize objects is called astereog- 
nosis. Their cortical localization has been discussed. 

Disturbances in touch occur as a result of lesions in the cortical sensory 
centres or in the postcentral and parietal convolutions. It is character- 
istic of the anesthesias the result of such lesions that they are never com- 
plete and may be segmental in their distribution, as, for instance, a patient 
may be able to recognize touch over the radial side of the hand and not 
over the ulnar. A complete disturbance of sensation is nearly always 
indicative of a lesion in the fibers away from the cortex, generally in the 
posterior portion of the posterior limb of the internal capsule. Such a 
lesion will produce complete hemianesthesia, not only for touch, but also 
for pain and temperature. 

Disturbances of pain or of heat and cold sensation do not occur indi- 
vidually as the result of cortical lesions, for, as a rule, when they are 
present they are always associated with disturbances of touch. Disturb- 
ance of touch sensation is the only form then which can occur alone as 
the result of cortical lesions. Sometimes, however, if there is an irrita- 
tive lesion of the sensory cortical centres, there may be attacks of numb- 
ness or of pain in the corresponding or associated limbs on the other side 
of the body. These spasms of pain can be compared to the Jacksonian 
convulsions which are the result of irritation of the motor centres. 

Alterations in the senses of localization, of movement, of position, and 
of pressure do not occur individually, and if there is disturbance in one 
there are disturbances in all. Should such be the case, the patient will 
be unable to recognize where he is being touched (sense of localization), 
whether a limb or a part of a limb has been moved (sense of movement), 
the position in which the limb has been placed (sense of position), and 
whether any pressure is exerted when objects are placed in his hand (sense 
of pressure). All these make up muscle sense. If these alterations are 
present, the patient cannot recognize any object placed in his hand, that is, 
he has astereognosis. Combined with this there must be incoordination 
of the limbs or limb, depending upon the site of the lesion. Disturbances, 



DISEASES OF THE BRAIN AND ITS MENINGES 163 

then, of these functions are always indicative of a lesion in the parietal 
lobules, in the superior if the lower limbs are involved, and the inferior 
if the upper. Disturbance in touch nearly always accompanies the 
above symptoms unless the lesion is limited to the parietal convolutions 
and to the cortex, a rather rare occurrence. 

The incoordination which is ^present as a result of cerebral lesions 
differs from that which is due to cerebellar or posterior column spinal 
disease in the fact that it is always unilateral and limited to the limbs, 
depending upon whether the superior or inferior or both parietal lobules 
are involved; whereas, in cerebellar ataxia there is incoordination in all 
the motor functions, and in spinal-cord lesions the ataxia is bilateral 
and limited to the limbs. 

Disturbances in Vision.— Disturbances in vision as a result of cerebral 
lesions may consist either of a diminution or loss of vision and of such 
alterations as are the result of paralysis of one or more of the ocular 
muscles. Under the head of cortical localization have been discussed 
the visual centres and the results of lesions either in this part or in the 
primary visual centres, optic tracts, chiasm, and nerves. Under the head 
of cranial nerves the ocular palsies have also been considered. 

Disturbances in the Special Senses.— Disturbances in the special senses, 
such as hearing, smell, and taste, occasionally occur as a result of destruc- 
tion of their cortical centres, but this is an extremely rare occurrence. 
They are mostly due to the involvement of their respective cranial nerves. 

Alterations in Mentality. — Alteration in mentality may result either 
from lack of development, such as occurs in idiocy and imbecility; it 
may come on for no apparent reason, as is the case in different forms of 
insanity; or it may be the result of definite lesions, such as brain tumors, 
abscesses, and injuries to the head. 

In idiocy and imbecility there is lack of development of the whole 
cerebrospinal system. The brains of such individuals are usually smaller, 
there is not the usual conformation, and the convolutions and fissures 
are not well developed. The prognosis is never good, and the only hope 
is that offered by education. 

The different forms of insanity w^ill not be considered here. It will 
only be necessary to say that in the course of some insanities patients 
develop delusions that they have certain diseases for which operations 
may be considered. Such operations are absolutely unjustifiable, and will 
have no beneficial effect upon the delusions and w^ill only multiply them. 

Lesions in any portion of the brain will necessarily influence men- 
tality, this depending upon the location and extent of the lesion. Inju- 
ries to the brain will also cause disturbances in mentality, this depending 
upon the extent of the injury. 

The question often arises whether it is possible to have insanity 
resulting from injury to the brain. Opinions differ regarding this, but 
it is probable that this is not possible. 

Brain Tumors. — Under this head will be considered tumors, abscesses, 
areas of softening, or whatever else may give the symptoms of a neoplasm 
in the brain. The most common form of tumor is the sarcoma, next in 



164 DISEASES OF THE NERVOUS SYSTEM 

order being glioma, endothelioma, fibroma, fibrosarcoma, carcinoma, 
tuberculoma, syphiloma, adenoma, etc. 

Sarcoma. — ^This form of brain tumor is probably more common than 
glioma. The growth may be small, flat, or nodular, or may be of large 
size. It is primary and usually solitary. Sarcoma always grows from 
the meninges, periosteum, or cranial bones, or from the pial covering 
of the bloodvessels. It never grows from the brain substance, and 
therefore, unlike the glioma, it always compresses the brain tissue and 
may be distinct from it, although not infrequently it infiltrates the latter. 
Even when growing within the brain a distinct margin may be sometimes 
found, due to the softened area surrounding it. It is usually harder in 
consistency than the glioma, slower in growth, and very vascular. 

The tumor may soften or caseate, and myxomatous, hemorrhagic, and 
cystic changes are not uncommon. Cystic changes are especially com- 
mon in the cerebellum, not only in sarcomata but also in gliomata. If 
the fibrous tissue is very marked we have a fibrosarcoma. 

Sarcoma may manifest itself as a diffuse multiple sarcomatosis. This 
may involve, first, the nervous substance and the meninges, and secondly, 
the membranes only, when it may appear in the form of small tumors 
or as a diffuse infiltration. When the brain or its meninges are impli- 
cated in sarcomatosis, in about two-thirds of the cases a tumor of the 
cerebellum is found. Tumors may also be found in the fourth and 
lateral ventricles, Gasserian ganglia, and pituitary body, in fact almost 
anywhere. 

It is important to remember that when sarcomatosis is present the 
soft tumor masses grow in the pia about the cranial nerves and spinal 
roots and may produce little or no compression or destruction of the 
nervous tissue. It is because of this that few clinical symptoms may 
appear, although there may be extensive alterations in the nervous tissue. 
A correct diagnosis of sarcomatosis of the brain and the pial covering is 
often impossible. 

Isolated sarcomata are, next to fibromata, among the most favorable 
forms of tumor for surgical removal. Of course, the question of multiple 
sarcomatosis must always be carefully considered when deciding upon 
operation. With regard to surgical procedure, the hard, non-infiltrating 
sarcomata are the most favorable. Experience shows, however, that a 
sarcoma which appears to be infiltrating when the brain tumor masses 
are first exposed is often separable from the brain substance. 

Endothelioma. — ^This is a form of sarcoma which grows either from the 
endothelial lining of the dura or from the perivascular spaces. It differs 
only from sarcoma in that the cells are arranged in clumps or columns 
and that it is more vascular. It never infiltrates the brain tissue, but 
compresses it and is a very favorable growth for removal. When it is 
present there may be an accompanying overgrowth of the cranial bones 
covering it. 

Osteosarcoma. — Occasionally a sarcoma will grow from the cranial 
bones, or it may involve the cranial bones secondarily. In such cases the 
tumor is called an osteosarcoma. 



DISEASES OF THE BRAIN AND ITS MENINGES 165 

Glioma. — ^This form of tumor is almost always primary and single, 
although metastasis may rarely occur. The tumor may be as small as 
a cherry or as large as a hen's egg. It always grows from the brain 
substance itself and is of slow growth. It is not sharply defined, but 
infiltrates the brain substance, and is difficult to distinguish from normal 
brain tissue, although sometimes there is an increased consistence and 
there may be a slight swelling. The border zone of the tumor may 
present an increased number of bloodvessels, and there may be islets 
of new tissue. 

Gliomata may be hard or soft, depending upon the excess of cells or 
fibrils, and have a yellowish white or reddish appearance. Cystic forma- 
tion is very common and it is possible that the whole mass may disappear, 
leaving nothing but a cyst wall, and it is necessary to examine micro- 
scopically the capsule to determine the gliomatous origin. Cysts form 
in the neighborhood of these tumors, and a surgeon may tap one of these 
cyst formations, believing it to be the only lesion present. It is always 
a wise procedure to remove a part of the cystic wall for microscopic 
examination. The fluid inside of these cysts may be whitish or bloody 
in character. Fatty, hemorrhagic, and myxomatous changes occur in 
gliomatous tumors. 

Microscopically it is difficult to distinguish a glioma from sarcoma 
unless a differential stain has been employed. There is some doubt as 
to the simultaneous occurrence of glioma and sarcoma, the so-called glio- 
sarcoma, as the former is of ectodermal and the latter of mesodermal 
origin. A gliosarcoma should be diagnosticated only when a sarcomatous, 
perivascular, cellular mass is found within the glioma. It can be readily 
understood from the slow growth and from its infiltrating character 
why clinical symptoms of brain tumor do not always appear or not until 
late in the disease. Surgically, it is difficult or even impossible to remove 
completely such a tumor. 

Glioma, sarcoma, and cysts of various kinds are more frequent in the 
adult, and tuberculous growths are more common in persons below the 
age of twenty years. 

Tuberculoma. — ^Tuberculous growths occurring in childhood are more 
frequently located in the cerebellum than in any other portion of the brain. 
In the adult they are found with equal frequency in this region, and in 
the pons and cerebral cortex. They are nearly always multiple and 
secondary to a tuberculous process elsewhere in the body. A tendency 
to symmetrical arrangement is also sometimes observed. Their size 
varies from that of a small nodule to that of a large fist. Macroscopically 
it is hard to distinguish a tuberculoma from a syphiloma. Both have 
poor blood supply and a tendency to caseate; the tuberculous growth tends 
to pus formation. Again, both have a tendency to grow from the meninges, 
although the tuberculous growths are found in the substance of the 
brain and may have granulation areas and miliary tubercles about their 
border. 

The growth of a tubercle may be either rapid or slow. Tuberculous 
tumors may give no clinical symptoms. This has been explained by the 



166 



DISEASES OF THE NERVOUS SYSTEM 



slowness of the growth, the brain tissue gradually accommodating itself 
to increased pressure. It is possible, however, to demonstrate by certain 
silver stains the persistence of the axis cylinders in these growths, thus 
explaining the persistence of function. Surgically, it is not advisable to 
operate upon tuberculous tumors, as they are multiple and cannot all be 
removed. A tuberculous growth may be part of a general tuberculous 
meningitis or there may exist tuberculous meningitis alone. If the symp- 
toms of meningitis arise, it is always a wise procedure to look for a tuber- 
culous process in the lungs as an aid to diagnosis. 

Syphilitic Growths. — Gummata are rarely found postmortem, although 
they are usually thought to be the most common form of brain tumor 
(Fig. 52). The usual results of syphilis in the nervous system are 
endarteritis, round-cell infiltration, and meningitis. The endarteritis is 
usually general, and, because of the weakening of the bloodvessel walls, 
early hemorrhages may result. 

Fig. 52 




Gumma of the m.otor cortex and meninges, showing extensive round-ceil infiltration throughout 
the whole section. Area (a) shows a gap in the tissue made at postmortem because of adhesion 
of brain and meninges to cranial bones. Clinically there were Jacksonian convulsions limited 
to the upper limb, followed later by paralysis. 



Syphilitic meningitis usually involves the basal membranes, but may 
also involve those of the cortex. In the latter instance the meninges 
may be a half-inch in thickness and thereby compress the brain and give 
focal symptoms of tumor. Occasionally the syphilitic process involves 
the brain substance itself, causing a diffuse cellular infiltration, or the 
bones may be involved, causing a carious condition of a part or many of 
the cranial bones. 

When basal meningitis occurs it may involve the whole extent, or, 
what is more often the case, only the meninges near the chiasm, thus 
involving the second, third, fourth, and sixth cranial nerves. 

At times, instead of meningitis there may be diffuse areas of softening 
throughout the brain, these areas being yellowish red in color, soft in 
consistency, and well defined from the surrounding brain tissue. 



DISEASES OF THE BRAIN AND ITS MENINGES 167 

Syphilitic growths are usually rapid in development, but it must be 
remembered that the various pathological conditions which lead on to 
the growths have long been present. 

Fibromata. — These tumors are rare, but they are relatively more fre- 
quent in the cerebellum than in the cerebrum, and especially in the 
cerebellopontile angle. 

A fibroma invading the cerebellopontile angle, or the angle between 
the pons and the cerebellum, may be only part of a general neurofibro- 
matosis. This, however, is rare, and usually a tumor in this area is the 
only expression of this process. The growth is slow and generally 
unilateral, although in rare instances it may be present on both sides. 
Experience has shown that it is more common on the left side in the 
ratio of three to two. 

The fibroma may be as small as a cherry or the size of a large egg. 
The growth is firm, hard, nodular, and has a distinct capsule surround- 
ing it. When located in the cerebellopontile angle it is generally loosely 
attached to the brain by an atrophic nerve trunk and a few blood- 
vessels or a meningeal process. These attachments may be easily rup- 
tured. These tumors are in organic relations, especially with the acoustic 
nerve, and more rarely with the trigeminus and facial nerves. They 
nearly always grow from the endoneurium and rarely from the perineu- 
rium or epineurium. Consequently it is possible to find meduUated nerve 
fibers either in the periphery of the tumor or in its centre. As a rule, if 
many cranial nerves are involved, there is a general neurofibromatosis. 

The fibroma may undergo a cystic, fatty, or myxomatous degeneration. 
Very often in the advanced stages it may assume a sarcomatous tendency. 
Histologically there is present connective-tissue structure, with entire 
absence of nerve elements except sometimes a few medullated nerve 
fibers either in the periphery or its central part. These are remnants 
of the nerve on which the fibroma grows, and should not be mistaken for 
a part of the newgrowth. 

Sometimes in association with fibroma of the cerebellopontile angle 
there may be cortical changes consisting in hyperplasia and hypertrophy 
of the glia cells of the cortex, or there may be present an endothelioma or 
psammoma of the dura mater. At times the fibromatous process may 
involve the whole intracranial portion of the acoustic or other nerves. 

These tumors compress greatly the lateral lobes of the cerebellum, the 
pons, and the medulla oblongata. At times even the temporal lobe may 
be compressed. Because of the slow growth and nature of the tumor 
clinical symptoms may not appear at all or only late in the disease. 
Tumors of the cerebellopontile angle are among the most favorable 
for surgical removal. 

Carcinoma. — Carcinoma of the brain is always secondary to growths 
elsewhere in the body, generally in the stomach, lungs, or breast. 
The tumor may grow in the substance of the brain, but mostly it grows 
from the dura or the cranial bones. It may be as small as a millet 
seed or may be of large size, and may occur anywhere in the brain 
substance. At times there may be an infiltration of cancer cells in the 



168 



DISEASES OF THE NERVOUS SYSTEM 



Fig. 53 




pia, covering the whole brain substance. This, however, is a rare 
occurrence. The possibihty of toxic changes must be considered, as it is 
not improbable that through intoxication caused by carcinoma elsewhere 
in the body, symptoms of tumor may be present. 

Such other tumors as osteoma (Fig. 53), adenoma, cholesteatoma, lipoma, 
and psammoma very rarely occur in the brain, and, as they do not differ 
from similar growths elsewhere, will not be considered. 

Cysts. — Cystic degeneration of 
gliomata and sarcomata is very 
common and has already been dis- 
cussed. Other tumors, as fibroma 
/ ^k and carcinoma, are prone to un- 

/ "^fe dergo cystic change, but more 

rarely. It is possible for the 
whole tumor to disappear and 
only the cyst remain, so that 
microscopic examination will be 
necessary to detect the small 
tumor mass in the walls of the 
cyst. 

Congenital cysts may occur in 
the fourth and lateral ventricles 
or in the substance of the brain. 
This, however, is a rare occur- 
rence. 

The most common cystic changes 
found in the brain are due to para- 
sitic growth, the cysticercus cellu- 
losace and the echinococcus. These, 
however, are so rare in this country that they will not be considered. 

Cysts due to traumatism may occur, but their genesis is by no means 
clear. It is probable, however, that they are the result of a hemorrhage 
which has occurred at birth or soon after. As the brain tissue at this 
time of life is not fully developed, cystic changes or porencephalus may 
result. 

Cystic tumors occasionally grow from the choroid plexus in any of 
the ventricles. These rnay not give any symptoms, but, if suflSciently 
large, will compress the ventricular walls and the surrounding brain tissue. 
The Influence of Brain Tumors upon the Surrounding Structures. — At 
operation when the dura is removed there is nearly always increased 
tension and the parts may bulge. The surface of the brain is flat and 
the fissures may be abolished, and the pia covering the neoplasm is 
generally poor in blood supply. The tissues near the growth may be 
softened. Pressure symptoms nearly always result, this depending 
upon the nature of the tumor, the extent of its growth, and its location. 
The greatest pressure is nearly always exerted upon the nearby structures, 
but often a tumor of the cortex may exert pressure upon the cranial 
nerves at the base of the brain. 



Osteoma of right frontoparietal bones, caus- 
ing pressure upon the brain with left hemiplegia. 



DISEASES OF THE BRAIN AND ITS MENINGES 169 

The cerebrospinal fluid may be increased in brain tumor, but this is 
especially so when the growth is in the posterior cranial fossa, because 
pressure here is exerted directly upon the communication between the 
lateral and fourth ventricles or upon the veins of Galen, which convey 
the blood from the choroid plexus to the sinus rectus. Because of this, 
increased tension results in the lateral and third ventricles, the latter 
causing direct pressure upon the optic nerves. 

Internal Hydrocephalus. — ^This condition is most often caused by brain 
tumor, but in children it is either congenital or the result of some early 
pathological condition. The cerebrospinal fluid is probably secreted 
by the choroid plexus, and, if there is any interference with the normal 
outflow of the fluid, or, if there is an overproduction, there will neces- 
sarily result a dilatation of the ventricles, or internal hydrocephalus. 
The causes may be congenital, such as closure of the foramen of 
Magendie or of the aqueduct of Sylvius or an aberrant secretion of 
the choroid plexus. When this disease appears later in life the closure 
of one of these foramina may result from a basilar meningitis, which is 
usually of a tuberculous nature. Whatever the cause, the gradual in- 
crease of fluid in the ventricles will increase the size of the cranial cavity 
and cause pressure upon the brain substance, with consequent atrophy 
and loss of function. 

If the causes are congenital the child may be born with a very large 
head, but in most instances it does not become apparent until after birth, 
when it will be noticed that the development of the child both physically 
and mentally is delayed. The head gradually becomes large, especially 
in the frontal and middle portions, the fontanelles bulge and do not close, 
and the head sometimes assumes an enormous circumference. The 
face does not show any deformity, with the exception that the eyes may 
bulge. Coincident with this it will be noticed that the limbs do not be- 
come developed and soon show an increasing weakness, with rigidity 
and exaggerated reflexes and the Babinski phenomenon with contrac- 
tures. The mentality is poor, although sometimes there may be con- 
siderable development. Associated with internal hydrocephalus there 
may be a rachitic condition of the chest. 

There is a form of hydrocephalus known as external hydrocephalus, by 
which is meant an accumulation of fluid in the cortical meninges. This 
occurs nearly always in association with chronic meningitis and will be 
discussed under that head. 

Abscess of the Brain. — The localizing symptoms of an abscess of the 
brain are similar to those of any other lesion or growth. Because of the 
fact that most abscesses occur as a complication of middle ear disease 
or extension of such inflammation, most pus cavities or abscesses are 
to be found either in the temporal area, cerebellopontile angle, or in 
the cerebellum; or, what often happens, besides a lesion either in the 
temporal or cerebellar areas there may also be a meningitis with its 
accompanying symptoms. 

Speciflcally it cannot be said that there are any general symptoms 
which indicate an abscess in the brain (p. 236). There may be, as is 



170 DISEASES OF THE NERVOUS SYSTEM 

usually the case in any growth, headache, nausea, vomiting, vertigo, and 
sometimes choked disk, these depending upon the extent of the lesion 
and the pressure exerted in the cranial cavity. There may or may not 
be changes in the temperature, such as result from pus elsewhere, and a 
slow pulse. The other symptoms will depend upon the location of the 
lesion, whether temporal or cerebellar. 

Fig. 54 




Abscess in pia in left cerebellopontile angle, causing cerebellar incoordination and paralysis of 
the sixth, seventh, and eighth nerves on the same side. Drawing shows wall of abscess. 

The Diagnosis of Tumors of the Cerebrum. — In the preceding pages the 
individual symptoms of tumors have been considered and analyzed, and 
continuous reference will be made to their contents. The collective 
symptoms as they occur in brain tumors will now be discussed. 

The general symptoms of brain tumor are headache, nausea, vomiting, 
vertigo or dizziness, and choked disk. As a rule, all these symptoms are 
present in a tumor of fairly large dimensions, but a growth may exist 
without the presence of any of these. Such a growth, however, must be 
small and of such character as not to cause pressure. The symptoms 
which are present in the great majority of cases are headache and 
choked disk. 

The headache may be localized to the site of the lesion, but, as a rule, it 
is general. Choked disk occurs in about 90 per cent, of cases, and may be 
greater on the side of the tumor. The swelling of the optic nerves is 
always greater in cerebellar lesions and comes on earlier than in cerebral 
lesions. 

Nausea, vomiting, and vertigo are especially prone to be present when 
the growth is large and great intracranial pressure exists. These symp- 
toms are also more liable to be present in tumors which press upon the 
medulla, as is the case in occipital lesions and in tumors of the cerebellum. 



DISEASES OF THE BRAIN AND ITS MENINGES 171 

When considering the symptoms of brain tumors, the side on which 
such a growth occurs must be taken into consideration. Tumors 
which are located on the left side of the brain can be more readily 
detected because our knowledge of localization is better on this side. 
This, of course, is in a right-handed individual. The contrary would be 
true of a left-handed person. 

It is, of course, impossible to tell, when the symptoms of a brain tumor 
are present, exactly what the nature of the growth may be. If there are 
present elsewhere in the body certain conditions, such as carcinoma, 
tuberculosis, or abscess of the lung, or, if there is a history or other evi- 
dence of syphilis, the presumption is justifiable that similar conditions 
exist in the brain, providing the symptoms come on in regular order. 
A growth in the cerebral cortex is more liable to be sarcoma or glioma, 
while in the brain-stem glioma and tuberculoma are more common. 

It is also important from a surgical point of view to differentiate 
between a cortical and a subcortical growth. A tumor which is cortical 
may in time involve the subcortex and a subcortical tumor may in time 
involve the cortex. Generally speaking, a cortical lesion will always give 
irritative phenomena. If in the motor cortex, there will result Jack- 
sonian convulsions on the opposite side, to be followed later by paralysis. 
If in the sensory cortex, there w^ill first be numbness and pains of the 
Jacksonian type, this to be followed later by anesthesia. If the location 
is in the occipital lobes, there will first be irritative visual phenomena, 
such as scintillating scotomata in the visual fields related to these areas, 
and later loss of vision. Generally speaking, then, in a cortical growth 
there will be irritative phenomena, to be followed by paralytic symptoms. 

In a subcortical groivth the symptoms will depend entirely upon what 
fibers are cut off, as, in the subcortex, a tumor, no matter how small, will 
always involve fibers concerned with more than one function. The symp- 
toms of a lesion in this area will always be greater in number than in a 
cortical lesion, for in the latter instance a tumor may involve only a very 
limited portion of the cortex, thus giving only a few symptoms. Again 
in a subcortical lesion irritative symptoms are not liable to occur, and 
the earliest symptoms are those of loss of function (Figs. 55 and 56). 

It is well known that tumors have a predilection for certain areas. 
These are the frontal, central or motor, parietal, occipital, and temporal. 
The symptoms which occur in growths of these parts will be taken up in 
order. 

Tumors of the Frontal Lobe. — Tumors in this area are not very common. 
The growths more often are of the sarcomatous variety and in most 
instances grow from the frontal bones or from the orbital plate. When 
the neoplasm is limited to the frontal lobe itself, there are, as a rule, very 
few localizing symptoms. In the frontal lobes have been placed the 
centres for higher psychic functions, this being especially so in the left, 
but it cannot be said that any special mental symptoms occur from de- 
struction of these areas. The usual mental symptoms are gradual change 
in disposition, and impairment of intellect, especially the memory and the 
power of reasoning. As can readily be seen, these symptoms may occur 



172 



DISEASES OF THE NERVOUS SYSTEM 
Tig. 55 




Subcortical gliomatous tumor (A), causing disturbance of motion and sensation on the opposite 
side. The symptoms were slow in onset, and, because of the nature of the growth, there were 
few general manifestations. A decompressive operation was performed by Dr. Martin. 



Fig. 56 




Horizontal sections of cerebral hemisphere, showing extent of gliomatous tumor infiltration. 
There was paralysis of the opposite side of the body, motor aphasia, headache, dizziness, and 
mild choked disk. 



DISEASES OF THE BRAIN AND ITS MENINGES 



173 



Fig. 57 



from tumors in any portion of the brain. Headache may or may not 
be present and is prone to be locaKzed to the orbit and frontal bones. 
Nausea, vomiting, and dizziness are not very common, and choked disk 
is a rather rare occurrence except in those instances in which the tumor 
is mostly localized to the orbital part of the frontal lobes and direct 
pressure is exerted upon the optic nerve, in which case the choked disk 
is unilateral. In the latter instance the olfactory nerve is also pressed 
upon, causing loss of the sense of 
smell on that side. If the tumor is 
of large size and involves the pre- 
central convolution, motor symp- 
toms will be present (Fig. 57). 

In the posterior portion of the 
second frontal convolution have 
been placed the centres for the 
movement of the head and eyes, 
and, if a lesion irritates these 
centres, conjugate deviation of the 
head and eyes or of both to the op- 
posite side will result. If the lesion, 
however, destroys these parts, the 
head and the eye will be directed 
to the side of the lesion. This is 
because of the unrestrained action 
of the muscles which are inner- 
vated by the opposite cortical cen- 
tres. If the lesion involves the 
inferior posterior portion of the 
third frontal, or Broca's, convolu- 
tion, motor aphasia will be present. 

The frontal lobes are in direct 
connection with the opposite cere- 
bellar lobe by the so-called fronto- 
cerebellar fibers. In a growih of 
the frontal lobe, in which the 
tumor is largely subcortical, cere- 
bellar symptoms may result, and 
it is difficult to differentiate the 
symptoms from those of cerebellar 
lesion. This, however, is a very 
rare occurrence. 

Another symptom which is sometimes supposed to be present is an 
abnormal tendency for poor jokes, or the "Witzelsucht" of the Germans. 
This, however, is of questionable value. 

The symptoms, then, of a tumor in the frontal lobe are headache, 
localized mostly to the frontal bones, occasional nausea, vomiting or 
vertigo, and occasional optic neuritis, which is mostly unilateral and 
confined to the side of the lesion. The special symptoms are loss of 
memory and change in disposition. 




Tumor of frontal lobe, causing disturbances 
of mentality with loss of memory and reasoning, 
also some headache and optic neuritis. 



174 DISEASES OF THE NERVOUS SYSTEM 

If the tumor is of large size and presses upon the adjoining motor areas, 
the above symptoms are accentuated, and there may be in addition motor 
symptoms which may be either of an irritative or a paralytic character 
and which are confined to the limbs of the opposite side, conjugate 
deviation of the head or eyes, or of both, and motor aphasia. 

Tumors of the Motor Area. — Growths in this location are more common 
than in any other portion of the cerebrum and are mostly sarcomata 
or gliomata. The symptoms will depend upon the location and extent 
of the lesion. If a growth is limited, for instance, to the centre for move- 
ment of the upper limb, the symptoms will be referred to this part. If 
the lesion is of large extent, the symptoms, of course, will be referred to 
the related parts. Jacksonian or focal convulsions nearly always result 
from a cortical lesion. A tumor, for instance, involving the centre for 

Fig. 58 




Tumor involving arm centre in precentral convolution. The symptoms were those of Jack- 
sonian convulsions in one arm followed by paralysis, accompanied by headache, nausea, vomiting, 
stupor, and choked disk. 

the upper limb will give Jacksonian convulsions beginning in this limb. 
If the growth extends downward, the movement will extend from the 
upper limb to the muscles of the head and face. If the growth extends 
from the middle to the upper portion of the precentral lobe, the con- 
vulsions will extend from the arm to the lower limb. It must be remem- 
bered that a convulsion that is first Jacksonian may become general in 
character, and that in an epileptic convulsion there may sometimes be 
Jacksonian manifestations. If the tumor destroys the motor areas, 
paralysis in the related parts will result. 

Lesions in the motor area are only rarely confined to the precentral 
convolution and mostly also involve the postcentral convolutions or the 
sensory centres, in which case sensory symptoms will be present in 
addition to the motor. If the lesion is irritative, there will be pains of a 
Jacksonian type in the limbs of the opposite side; or, if the lesion is destruc- 



DISEASES OF THE BRAIN AND ITS MENINGES 



175 



tive, disturbances of sensation or anesthesia in the related limbs on the 
opposite side will result. 

If the tumor involves the frontal lobes, and especially the head and 
eye centres, conjugate deviation will result to the opposite side if the lesion 
is irritative, and to the same side if the lesion is destructive. If the tumor 
is on the left side of the brain in a right-handed individual, motor aphasia 
will also be present (Fig. 58). 

As a rule, tumors in the motor area give symptoms of great pressure, 
and headache, nausea, vomiting, and choked disk are present in most 
instances. Some of these symptoms may, of course, be absent, but, as a 
rule, headache and choked disk are present. 

The symptoms then of a tumor confined to the motor area are headache, 
nausea, vomiting, choked disk, and Jacksonian convulsions on the oppo- 
site side, to be followed later by paralysis depending upon the extent of 
the lesion. 



Fin. 59 




Recurring sarcoma of motor sensory area. Tumor first removed by Dr. Martin. Symptoms 
were those of hemiplegia, incomplete hemianesthesia, and sensory aphasia. 

If the tumor invades the postcentral convolution, there are in addition 
sensory symptoms, such as pains and disturbances in sensation for touch 
and pain. If the growth invades the frontal lobes, there may be at first 
conjugate deviation of the head and eyes to the opposite side and later 
to the same side. A lesion in the left side of the brain in a right-handed 
individual will also always give motor aphasia. The contrary is true in 
left-handed persons. 

Tumors of the Sensory Area.— This includes the postcentral and superior 
and inferior parietal convolutions. Growths involving only this part are 
very rare, for in most instances the adjoining motor centres are also 



176 



DISEASES OF THE NERVOUS SYSTEM 



diseased. As lias already been stated, most tumors of the motor area 
involve the postcentral convolution (Figs. 59 and 60). 

Isolated tumors involving either the superior or the inferior parietal 
convolution may rarely occur. In such case a lesion of the superior 
parietal convolution will give disturbance in the sense of localization, of 
position, of movement, of pressure and ataxia of the lower limb, with 
inability to recognize objects placed against the sole of the foot. 

A lesion involving the inferior parietal convolution will give the above 
symptoms in the upper limb instead of the lower. In addition, in both 
there may be headache, nausea, vomiting, and choked disk. 




Sarcomatous growth removed postmortem. 

In most instances we have the adjoining postcentral convolution 
involved, and there is in addition to the symptoms already enumerated 
disturbance in touch and pain. Very often in irritative lesions of the 
sensory areas there may be numbness and paroxysms of pain in the 
related limbs similar in character to the Jacksonian spasms, the result 
of motor irritation. 

If the growth involves the adjoining occipital convolution, disturbance 
in vision will result. If the lesion is left-sided in a right-handed person 
and the angular gyrus is involved, there is in addition word and letter 
blindness, this causing inability to read or write voluntarily or from 
dictation. 

Tumors of the Occipital or Visual Area. — Growths in this area are not 
very common. They, as a rule, cause early pressure symptoms, and 
disturbances of vision are among the first manifestations. These may be 
flashes of light or scintillating scotomata in the related visual fields, to be 



DISEASES OF THE BRAIN AND ITS MENINGES 



177 



followed later by disturbance of vision, either for light or for colors, 
and lastly loss of half vision, or hemianopsia. If the lesion is right-sided, 
there will be left lateral homonymous hemianopsia, and vice versa. 
Occipital headache is always marked, as are also nausea, vomiting, and 
vertigo, and choked disk will come on early. This is because direct 
pressure is exerted upon the cerebellum. There may be in addition the 
symptoms of cerebellar incoordination (Fig. 61). 

If the growth involves the adjoining parietal or angular gyres, their 
related symptoms will occur. 



Fig. 61 




Endothelioma in one occipital lobe (a), causing the general symptoms of brain tumor with 
hemianopsia of the opposite side. 



Tumors of the Temporal Lobes. — Growths in this area are of rare occur- 
rence, in most instances the adjoining parietal lobes being also involved. 
If the lesion is on the left side of the brain in right-handed individuals and 
the growth is confined to the temporal lobes, the symptoms will be those 
of pure sensory aphasia, i. e., the patient will be able to talk, but he will 
have loss of memory for words as to their meaning and his speech will 
be unintelligible. 

If the lesion is on the right side of the brain in right-handed indi- 
viduals, no localizing symptoms will be present. This is a so-called 
"silent area" of the brain. There will, of course, be headache, nausea, 
vomiting, and choked disk. If the growth involves the adjoining parietal 
lobes, their related symptoms will occur. 
12 



178 



DISEASES OF THE NERVOUS SYSTEM 



Tumors in the Subcortex, Cms, Pons, and Medulla. — ^The symptoms of 
lesions in these areas will not be discussed, inasmuch as surgical removal 
of tumors in these areas is impossible. The localizing symptoms, 



Fig. 62 



_„^ 







z^^'^- 






/ w 






h'f-\ 


MMM!u\ 




%. 


m^^' 


" f 


^^^'' 


"^^T 


■J--' 


'^f 


0^ 


w ' 



Tumor of lateral ventricle causing pressure on internal capsule and optic thalamus, with 
hemiplegia and incomplete disturbance of sensation upon the opposite side, accompanied by 
headache, vomiting, vertigo, and choked disk. 



Fig. 63 




Tumor of aqueduct of Sylvius in the pons, causing blocking up of flow of cerebrospinal fluid 
and secondary internal hydrocephalus. There were only general pressure symptoms. 

however, have been discussed under the head of cortical localization. 
In addition to the symptoms there enumerated there will be the usual 
symptoms of brain tumor, such as headache, nausea, vomiting, vertigo, 
and choked disk (Figs. 62 and 63). 



DISEASES OF THE BRAIN AND ITS MENINGES 179 

Tumors of the Cerebellum. — Growths in the posterior cranial fossa 
may involve either the substance of the cerebellum or the surrounding 
structures, the latter giving the symptoms of cerebellar disease because 
of pressure or involvement of this organ. It is also necessary to consider 
growths which occur in the cerebrum, but which, because of pressure, 
give symptoms of cerebellar disease. 

The general symptoms of tumors of the cerebellum are headache, 
nausea, vomiting, vertigo, choked disk, and incoordination. 

Headache, as a rule, is present, is more severe in lesions of the cere- 
bellum itself than in extracerebellar lesions, and is generally localized to 
the back part of the head and neck. Sometimes the pain is so severe 
as to cause retraction of the head. Occasionally no headache is present. 

Nausea and vomiting are, as a rule, present early and are more intense 
in intracerebellar lesions. 

Vertigo is present nearly always and is one of the prominent symptoms. 
It may consist in a feeling of dizziness in which objects may swim before 
the eyes and the patient feels as if he were losing consciousness, or in a 
feeling of rotation of objects before the eyes or of rotation of self. Vertigo, 
as a rule, is more marked in extracerebellar lesions and is probably 
dependent upon involvement of the vestibular branch of the eighth nerve. 
It is the opinion of some that when there is a sensation of rotation of 
objects before the eyes, whether the lesion be intra- or extracerebellar, 
it is always from the diseased to the healthy side. A^Tien there is a 
sensation of rotation of self, the direction is the same in intracerebellar 
lesions, but opposite in extracerebellar lesions. This symptom, however, 
is by no means certain. 

Occasionally a sense of dizziness is experienced when the eyes are 
deviated to one side, generally to the side of the lesion, but there is no 
dizziness when the head is deviated. In such case the vertigo may 
be due to a weakness of one of the ocular muscles and is not a true 
cerebellar vertigo. 

Choked disk is one of the early and most constant symptoms of lesions 
in the posterior cranial fossa. As a rule, it comes on earlier and is 
more marked than in lesions of the cerebrum. It may be greater on the 
side of the lesion. Sometimes choked disk comes on after the appear- 
ance of other cerebellar symptoms, and, when it does so, its development 
is usually very rapid. Tumors of the substance of the cerebellum itself 
usually give a greater choked disk because of the direct pressure exerted 
upon the fourth ventricle. 

Incoordination results from a lesion in any portion of the cerebellum 
or its connections. As has already been stated, it is probable that the 
cerebellum is concerned with the coordination of every voluntary move- 
ment, and therefore whatever symptoms are produced are dependent 
upon this. 

A lesion in the middle portion or the vermis will produce the greatest 
amount of incoordination, this being apparent on either side of the body, 
whereas lesions involving only a lateral lobe will produce a preponder- 
ance of symptoms on the side of the lesion. Tumors outside of the cere- 



180 DISEASES OF THE NERVOUS SYSTEM 

bellum will produce mostly unilateral symptoms unless the middle lobe 
or the vermis is involved, in which case bilateral ataxic symptoms will be 
present. 

The incoordination of cerebellar disease is manifested only when an 
effort is made and is not dependent upon peripheral symptoms, i. e., 
there is never disturbance of sensation and no involvement of muscular 
sense. This incoordination becomes apparent in the gait, station, posi- 
tion of the head and limbs, movements of the eyeballs, head, and limbs, 
and in talking, eating, and swallowing. These will be taken up in 
order. 

When considering the ataxia present in cerebellar diseases it is neces- 
sary to consider also the possible influence of the weakness and the atonia 
which sometimes results from lesions of the cerebellum. This question 
is by no means settled, but there is no doubt that in lesions of the vermis 
itself there may be paresis or weakness in the muscles of the limbs and 
especially those of the trunk, and in lateral lobe lesions weakness has 
been found in the limbs and trunk muscles of. the same side. This can 
be readily seen after operations upon the cerebellum in which this 
organ has been injured. The weakness is not prominent and is not 
always present. It is also characteristic of cerebellar disease that the 
limbs, especially on the side of the lesion, lose their accustomed tone and 
are rather flaccid. This symptom is also by no means constant, and is 
present especially in lesions of the vermis. 

The gait in cerebellar diseases resembles that observed in a drunken 
person. The patient will make a few steps and then will totter or lurch 
to one side or the other or backward or forward, and, recovering, will 
repeat this over again. In lesions of the vermis this is most marked, but 
in lateral lobe and in extracerebellar lesions, in which the former is 
pressed upon, it will not be so prominent. Generally the patient will 
have a tendency to walk to one side, usually to the side of the tumor, 
and will occasionally have a tendency to fall to this side. If such a 
patient's gait were not corrected he would tend to walk in a circle, the 
side of the tumor being directed toward the centre of the circle. The 
patient is generally aware of this tendency to walk to one side, and in his 
effort to correct this will sometimes walk to the opposite side. 

As a rule, the closure of the eyes will not tend to increase the inco- 
ordination if the lesion is iti the vermis, but sometimes in lateral lobe 
and extracerebellar lesions the gait is distinctly made worse when the 
eyes are closed. 

If the motor columns are pressed upon, as is not infrequent in extra- 
cerebellar lesions, there is added a spastic condition, on the side opposite 
the tumor. A bilateral spastic condition is also often present when there 
is a complicating internal hydrocephalus. This spasticity to a certain 
extent will modify the incoordinate gait. 

The station and attitude of a patient with cerebellar disease depends 
largely upon the position of the growth. In lesions of the vermis itself 
there may be retraction of the head and extension of the lower limbs 
with flexion of the upper. There may also be lordosis in the lower por- 



DISEASES OF THE BRAIN AND ITS MENINGES 181 

tion of the spinal column. It has been supposed that the attitude and 
position of the trunk and head are considerably modified by the weak- 
ness which is supposed to be present in the erector spinse and other trunk 
muscles. This is questionable, for the alternate contraction of these 
muscles is probably only an effort to keep the parts above in their proper 
position, and is only a part of the general incoordination. Sometimes 
in tumors of the cerebellum the head is held in certain positions to pre- 
vent the growth from pressing directly upon the vermis. In tumors, for 
instance, of the left lateral lobe the patient will be inclined to lie on his 
left side, for, when he lies on the right, pressure may be exerted upon 
the vermis. This symptom, however, is not by any means constant. 
Very often also patients with cerebellar tumors will hold their heads in 
abnormal positions, not because of the possible influence the change of 
position would have upon the vertigo and dizziness, but because they 
see double and by holding their heads in certain positions they are able 
to avoid this. 

If the patient is placed with his feet together he will have a tendency to 
fall, generally to the side of the lesion. As a rule, if the eyes are closed, 
the ataxia will be increased, and this is especially so in extracerebeliar 
lesions. 

The incoordination, or ataxia, which is 'present in the limbs is of two 
types, i. e., it may be made worse with the eyes shut, or this may have no 
influence upon it. This ataxia is dependent upon the lack of coordina- 
tion in the muscular contractions and is not dependent upon any sensory 
disturbances. As a rule, it is greatest on the side of the lesion, but it 
may also be observed on the opposite side. If the upper limb on the side 
of the tumor is moved in any direction, for instance, as in supination and 
pronation, it will be found that the movement will not be so well nor so 
rapidly performed as upon the other side. The same thing is true if 
the lower limb is moved. These symptoms are dependent upon the lack 
of coordinate contraction of the muscles concerned in the movements. 

Incoordination in the movement of the eyeballs, or nystagmus, is present 
nearly always in lesions of the cerebellum, and is similar to that observed 
in any other movement. It is present only when the eyeballs are moved, 
and is greater when the eyeballs are directed to the side of the lesion. 
The nystagmus may consist of to-and-fro jerkings of the eyeballs and is 
greatest in lateral deviation. 

Incoordination of the muscles which are concerned in talking, eating, 
and swallowing occurs occasionally in lesions of the middle lobe of the 
cerebellum, and must be differentiated from the difficulty observed when 
an extracerebeliar tumor presses upon the cranial nerves supplying the 
muscles necessary to perform these acts. 

Cranial Nerve Symptoms. — ^The cranial nerves, as a rule, are not 
involved in lesions of the middle lobe of the cerebellum. In tumors of 
the lateral lobe it is possible to have involvement of the fifth, sixth, 
seventh, and eighth cranial nerves on the same side, but, as a rule, such 
cranial nerve involvement indicates a tumor in the angle between the 
pons and cerebellum, or the cerebellopontile angle. 



182 DISEASES OF THE NERVOUS SYSTEM 

The first, or olfactory, nerve is hardly ever diseased. The same is true 
so far as the third and fourth cranial nerves are concerned. 

The fifth cranial nerve may sometimes be involved, especially in extra- 
cerebellar lesions. Very rarely a tumor may grow from this nerve. 

Unilateral involvement of the sixth nerve is a very common symptom 
in extracerebellar lesions. Bilateral sixth nerve paralysis may some- 
times be present in unilateral lesions, but, as a rule, this indicates a tumor 
in the middle lobe or the vermis. 

The sevejith nerve is nearly always involved in tumors of the cere- 
bellopontile angle, and a fibroma may grow from this nerve. A lateral 
cerebellar tumor may sometimes cause involvement of this nerve by 
pressure. 

Tumors of the cerebellopontile angle, as a rule, grow from the eighth 
nerve and are generally fibromata. At first there may be such subjective 
symptoms as roaring, hissing, or buzzing noises in the ear, and later 
complete nerve deafness. This nerve may be involved by pressure from 
a growth in the lateral lobe of the cerebellum. 

The ninth, tenth, eleventh, and twelfth nerves may be involved by 
pressure from extracerebellar lesions, causing difficulty in talking, eating, 
and swallowing. Bilateral involvement is uncommon and, as a rule, 
indicates a lesion in the medulla itself. 

Pupillary Symptoms. — ^Tumors of the cerebellum probably have no 
direct effect upon the condition of the pupils, alterations in them probably 
depending upon the presence of optic neuritis or choked disk. 

Motor Symptoms. — The weakness or paresis which is sometimes 
present in cerebellar lesions has already been discussed, and is not de- 
pendent upon pressure on the motor columns. An extracerebellar tumor 
usually compresses the motor fibers of the pons, and this causes the spastic 
condition on the opposite side with the consequent weakness, increased 
reflexes, and the presence of the Babinski phenomenon. In complicating 
internal hydrocephalus this condition may be bilateral. 

Lesions of the cerebellum usually have no influence upon the state 
of the reflexes, which may be increased, lost, or in normal condition. 

Convulsions. — Convulsions, either general or limited, sometimes occur 
in. the course of cerebellar disease. If general, as sometimes occurs in 
lesions limited to the vermis, there is retraction of the head, extension 
of the lower limbs and flexion of the upper, and the whole body is held 
in tonic contracture. 

Tumors which involve the seventh nerve may cause tremors in its 
distribution and sometimes convulsions which are limited to this nerve 
and are focal or Jacksonian in character. Instead of this there may 
occur irregular fainting spells, during which time the patient feels giddy 
and has a tendency to fall. These are not really convulsions and are 
dependent upon the vertigo common in this disease. 

In diagnosticating tumors of the posterior cranial fossa it is necessary 
to consider whether the growth is cerebellar or extracerebellar, and, if 
the former, whether the tumor is locaUzed to the centre or to the lateral 
lobe (Fig. 64). 



DISEASES OF THE BRAIN AND ITS MENINGES 



183 



Summarizing the symj)toms of a tumor in the vermis, we have as follows : 
headache in the back of the neck, excessive nausea and vomiting, intense 
vertigo, early and marked bilateral choked disk; marked incoordination 
in every movement of the body, whether in the limbs, trunk, movements 
of the eyeballs, and sometimes in articulation, eating, and swallowing; 
sometimes weakness in the limbs and the muscles of the trunk with atonia, 
an ataxic gait, poor station, and rarely so-called cerebellar fits, during 
which time the head is retracted, the legs extended, and the arms flexed, 
all in tonic contracture. 

Tumors of the lateral lobe of the cerebellum give headache, nausea, 
vomiting, intense vertigo, early and marked bilateral choked disk, 
which may be greater on one side, incoordination in all movements of the 
limbs is greater on the side of the lesion, a staggering gait with a 
tendency to lurch toward the affected side, nystagmus, more marked in 

Fig. 64 




Tumor of the fourth ventricle, causing pressure on the middle and lateral lobes of the cerebellum. 
There was cerebellar incoordination of the whole body and an ataxic drunken gait, some weak- 
ness in the limbs, headache, excessive dizziness, nausea, vomiting, and choked disk. 



looking toward the side of the lesion, sometimes paresis and atonia in 
the limbs of the same side, and, if the tumor is large pressure upon the 
cranial nerves of the same side. 

Extracerebellar lesions may arise either in the angle between the pons 
and the medulla, i. e., the so-called cerebellopontile angle, or may grow 
from the occipital or temporal bone primarily, and secondarily involve 
the structures in the cerebellopontile angle and the cerebellum itself. 

Tumors of the cerebellopontile angle are usually fibromata and grow 
from the eighth, seventh, fifth, and sixth nerves in order of frequency, and 
the first symptom will depend upon which nerve is involved. If the 
growth is on the eighth nerve, there is first a roaring, buzzing, or hissing 
noise on the side of the tumor, to be followed by deafness and then the 
symptoms of paralysis of the seventh and sixth nerves, and more rarely of 
the fifth nerve, as these nerves are pressed upon. There are, in addition, 
headache, nausea, vomiting, vertigo, which may be excessive if the eighth 



184 



DISEASES OF THE NERVOUS SYSTEM 



nerve is diseased, and choked disk, which, as a rule, is greater on the side 
of the tumor. When the cerebellum is pressed upon there are added 
incoordinate symptoms in the limbs, greater on the side of the lesion, 
paresis, and atonia, only rarely on the side of the tumor, a staggering and 
incoordinate gait to the^ side of the tumor, and less frequently nystag- 
mus, which is greater when the eyes are deviated to the affected side. 
If the tumor grows from the seventh nerve, spasms in its distribution 



Fig. 65 




Fibroma growing from the left acoustic nerv^e compressing slightly the left lateral lobe of the 
cerebellum and the lower surface of the left temporal lobe. 



may be observed. As a rule, the growth will press upon the motor fibers 
of the pons, causing weakness and spasticity with increase of reflexes in 
the limbs of the opposite side (Fig. 65). 

If the tumor grows from the dura covering the occipital or the temporal 
bone, the symptoms may be a little more diffuse, being the same as those 
above enumerated in tumors of the cerebellopontile angle plus involve- 
ment of some of the cranial nerves on the opposite side. 

Sometimes diffuse syphilitic lesions in various portions of the brain or 
a pial infiltration at the base of the brain may give the symptoms of a 
cerebellar tumor to such an extent that it is almost impossible to make a 
differential diagnosis. There may be present all of the general symp- 



DISEASES OF THE BRAIN AND ITS MENINGES 185 

toms of a cerebellar lesion, but there will be in addition almost always 
a greater involvement of the cranial nerves, such as that of the third, a 
very unusual condition in pure cerebellar or extracerebellar lesions. 
Multiple sarcomatous tumors may also give the symptoms of a tumor 
in the cerebellum or of the angle, and in such instances it is almost impos- 
sible to differentiate the symptoms from those resulting from basal 
syphilis. 

Injuries to the Brain. — This subject is fully discussed elsewhere 
(p. 223), As a rule, if the injury is severe enough there will be impair- 
ment of consciousness. If this is complete, so that the patient cannot 
be aroused, it is called coma. If the patient can be aroused so that 
questions are answered, it is called stupor; whereas an expression 
of wandering ideas accompanied by stupor is called delirium. No 
matter how slight the injury, there may be an accompanying fright 
which leaves its mental impression, and furnishes one of the causes 
of the traumatic neuroses. In those cases in which unconsciousness 
results from the injury, if the patient rallies, this element of functional 
disturbance may enter. Its influence will be discussed under the head 
of traumatic neuroses. 

In most instances the period of unconsciousness W\\\ not last long, and 
the patient will rally within a few hours, but sometimes the stupor 
may persist for a number of days and even longer. It is possible for the 
patient to regain consciousness and again lapse into stupor, especially 
when there is a progressive hemorrhage. As a rule, if the patient rallies 
within a few or less than twenty-four hours the prognosis is good, whereas 
stupor lasting for more than a day will make the prognosis very grave. 
It is necessary in a great many instances to diagnosticate such a comatose 
condition from those arising in alcoholism, uremia, diabetes, and hysteria. 
There should, however, not be much difficulty in making a differential 
diagnosis if the underlying causes are considered. 

Certain general symptoms may always be present whenever con- 
siderable compression of the brain from any cause exists. They are 
alterations in consciousness, disturbances in respiration and pulse, 
specific symptoms, as paralysis, depending entirely upon the position 
of the lesion; nausea, vomiting, vertigo, and choked disk. The severity of 
these symptoms will depend upon the rapidity of onset and the extent 
of the pressure. In those cases in which the pressure is sudden, such 
as from large hemorrhage, the symptoms will be marked and prompt, 
whereas in slow bleeding they Avill develop slowly. 

The most important factor in the prognosis is the state of the respira- 
tion and pulse. Disturbance in respiration is an early symptom of com- 
pression, and there may be slowing in the rate, arhythmical or stertorous 
breathing or the typical Cheyne-Stokes type, the occurrence of the latter 
nearly always affording a grave prognosis. The pulse in cerebral com- 
pression is nearly always slow, its rate sometimes being as low as 40 
to the minute. The blood pressure usually is high, and when meas- 
ured by the Stanton apparatus it may be 250 or more. The increase 
in the peripheral blood pressure is an attempt of Nature to equalize the 



186 DISEASES OF THE NERVOUS SYSTEM 

lessened pressure within the cranial cavity, and therefore such procedure 
as peripheral bleeding is contra-indicated. A temperature of 105° to 
107° is a not infrequent precursor of a lethal termination. 

Fracture of the Base of the Skull. — (See p. 228.) It is upon the focal 
symptoms that the diagnosis of fracture of the base must be made. 
This will depend upon the line of fracture and upon the possible exist- 
ence of a hemorrhage. In nearly all cases some of the cranial nerves 
will be involved, and of these the optic and the sixth, seventh, and 
eighth nerves are most commonly the seat of injury. 

The first, or olfactory, nerve is frequently involved from a fracture in 
any portion of the skull, probably because of injury to the ethmoid, 
unilateral or bilateral loss of smell, and impairment of taste resulting. 

The second, or optic, nerve is very frequently injured, either on one or 
both sides. This may be either because of a hemorrhage in or about the 
optic chiasm, or, what is more frequently the case, because of fracture 
through the optic foramina. The impairment of sight will depend upon 
whether one or both optic nerves are diseased and upon the part of the 
nerve which is injured. Very frequently there will be neither fracture 
through the optic foramina nor hemorrhage involving the optic nerve, but 
a momentary pinching of the nerves. Whether this causes a hemorrhage 
into the sheath or into the nerve itself, or whether it causes a destruction 
of fibers with a consequent atrophy, is not known, but the fact remains 
that such pinching will in many cases result in a diminution and some- 
times total loss of vision. In rare instances it is possible to have such an 
injury of the optic nerve with consequent optic atrophy without any other 
symptom, and more rarely still this impairment of vision may be in the 
form of irregular hemianopsia. 

The third, or oculomotor, nerve is rarely involved, but suffers when 
there is a fracture through the orbit and the middle cranial fossa. The 
lesion may be unilateral or bilateral. In most instances only part of 
the distribution of the oculomotor nerve is paralyzed, this resulting 
in drooping of the upper lid or possibly a weakness of some of the 
ocular muscles. 

The fourth nerve is only rarely diseased in injuries of the brain. The 
fifth nerve is sometimes involved in fracture of the middle cranial fossa, 
but its involvement is also rare. 

The sixth, seventh, and eighth nerves are probably more frequently 
involved in fractures of the base than the other cranial nerves, and, 
because the exits of these nerves at the base are so close together, they 
are often simultaneously affected. 

Very rarely the ninth, tenth, eleventh, and twelfth cranial nerves 
are injured, causing difficulty in eating, talking, and swallowing and 
irregularity of the pulse and respiration. These are only present in 
severe cases and nearly always result fatally. 

It is characteristic of these cranial nerve palsies that they are not of 
permanent duration, for in most instances, if the patient lives, a partial 
and sometimes a total recovery may be expected. 

Sometimes there results in fracture of the base of the skull hemor- 



DISEASES OF THE SPINAL CORD 187 

rhage from one of the basal arteries. The symptoms of this will depend 
entirely upon the place of hemorrhage and upon the structures com- 
pressed. In most instances the hemorrhage is in or about the optic 
chiasm, this causing paralysis of the ocular muscles and impairment of 
vision, and, if the hemorrhage is large enough, the general symptoms of 
compression, such as headache, nausea and vomiting, and choked disk. 

Summarizing then the symptoms of fracture of the base of the skull, 
there may be either coma, stupor, or delirium, which may last a few to 
twenty-four hours or a number of days and from which the patient may 
or may not rally, stertorous respiration, slow, irregular pulse, bleeding 
from the nose, throat, or ear, sometimes the escape of cerebrospinal fluid, 
subconjunctival or subcutaneous ecchymosis, and paralysis of some of the 
cranial nerves with irregular pupils. If there is an accompanying hemor- 
rhage into the substance of the brain, the symptoms will depend upon 
whether the motor, sensory, or special fibers are involved; if there is a 
fracture of the vault, the additional symptoms of this. 

The prognosis will depend upon the extent of the cranial nerve in- 
volvement, whether or not there are hemorrhages in the brain substance, 
and upon the stupor and the state of the respiration and pulse. The 
prognosis is always best where the patient rallies within a few or twenty- 
four hours, and the state of the pulse is the best indication of the results 
to be expected. 

Terminal Effects of Injuries to the Brain. — These will depend largely 
upon the character of the injury and its effects and the benefit of what- 
ever therapeutics have been employed. Injuries to the skull such as will 
involve the meninges and brain are among the most frequent causes of 
traumatic epilepsy. If the injury is over the motor area, Jacksonian 
convulsions may result, but very often injury anywhere in the brain, 
especially if this occurs in the young, may be followed by general or 
idiopathic epilepsy. Such other effects as hemiplegia or diplegia and 
impairment of vision and sensation need no further discussion. 

The mental symptoms are by far the most important. Very often a 
trivial injury w^ill cause a change in the disposition of the individual and 
produce more or less irregular headache, dizziness, lack of attention to 
business details, with the addition of many functional symptoms which 
will be discussed later. 

It is also a mooted question whether injuries to the brain can produce 
insanity. It is probable that in very rare instances it may cause the 
earlier appearance of insanity where there has been a predisposition for it, 
but it is hardly possible that direct injury to the brain can cause insanity. 
There is no denying, however, that mental impairment is not of infre- 
quent occurrence. 

DISEASES OF THE SPINAL CORD. 

Anatomical Relations. — The spinal cord is situated in the spinal 
canal and extends from the lower portion of the medulla oblongata to 
a point opposite the upper border of the second lumbar vertebra. It 



188 



DISEASES OF THE NERVOUS SYSTEM 



Arachnoid 
Dorsal root 
Ventral root 



consists of eight cervical, twelve thoracic, five lumbar, and five sacral 
segments. The cord is composed of gray and white matter, the former 
being in the centre and surrounded by white matter. The gray matter is 
divided equally on both sides of the spinal cord and is connected by a 
commissure and consists of an anterior and a posterior horn. It is com- 
posed of nerve cells and their dendritic processes, axis cylinders, nerve 
fibers, and neurogliar tissue which holds these structures in place. The 
white matter consists of nerve fibers and neurogliar and connective 
tissue, besides arteries, veins, and lymphatic vessels throughout the whole 
spinal cord. The nerve fibers which are situated in the white matter 
are bound together in bundles or tracts, each of which has a definite 
function. Normally these cannot be differentiated; it is necessary to 
have pathological processes or what is called secondary degeneration to 
bring out the different tracts (Fig. 66). 

From the nerve cells situated in 
the gray matter of the anterior 
horn come the so-called anterior 
roots which are motor in func- 
tion. The posterior roots enter 
into the spinal cord in an area 
called the entrance root zone, this 
being in the inner surface of the 
posterior horn of the gray matter. 
The fibers transmitted by the 
posterior roots come from the 
periphery and ascend into the 
spinal cord, and are sensory in 
function. On each posterior root 
is situated a collection of nerve 
cells called the posterior root gan- 
glion. The anterior and the pos- 
terior root then join together to form one nerve which goes through the 
dura. Each spinal segment has a pair of anterior and a pair of 
posterior roots which form two nerves coming off from the right and 
the left side of the cord. 

The spinal cord is surrounded by the pial sheath and is held in place 
by the anterior and the posterior roots and connective-tissue septa and 
by the cerebrospinal fluid, these structures being attached to and sur- 
rounded by the dura, which in turn is held in place in the spinal canal 
by the attached peripheral nerves (Fig. 67). 

Spinal Roots. — The anterior and posterior roots travel within the dura 
for various lengths before they join to form a peripheral nerve. It is 
necessary to know the place of exit of each nerve root, and an easy way 
to remember it is that every nerve root leaves the spinal canal at the bot- 
tom of the corresponding vertebra; thus, the second lumbar root leaves 
at the bottom of the second lumbar vertebra. There is an exception, 
however, so far as the cervical roots are concerned. There are eight 
cervical segments and only seven cervical vertebrae, so that the eighth 




alia 



Plexus venosus 



Transverse section of the spinal cord and its 
membranes. (Gegenbauer.) 



DISEASES OF THE SPINAL CORD 



189 



Fig. 67 

y. to rectus lateralis 

.—to rectus antic, minor 
Anastomosis with hypoglossal 

Anastoviosis with pneumogastric 
X. to rectus antic.major. 
N. to mastoid region . 
.Great auricular n. 
■Transverse cervical n. 
==^\^". to Trapezius, Ang. Scap. and Rhomboid . 



^Supra-clavicular n. 

_Supra-acromial n. 

.J'hrenic n. 

._N. to levator ang. scap. 
.-jS\ to rhomboid 
— Subscapular n. 
Subclavicular n. 




X to peetoralis major. 



.Circumflex n. 

Musculo-cutaneous n. 

Median n. 

Radial n. 

Ulnar n. 

Internal cutaneous n. 

Small internal cutaneous n. 



Jlio-hypogastric 7i. 
llio-lnguinal n. 



External cutaneous n, 
Genito-crural n. 



Anterior crural n. 
Obturator n. 



N. to levator ani— 
y. to obturator int. 
N. to sphincter an 
Coccygeal n 



Superior gluteal n. 



lY. to pyrifonnis 
X. to gemellus super. 



A', to nemeUus infer. 

iV. to quadratics 

Small sciatic n. 
Sciatic n. 

The relation of the segments of the spinal cord and their nerve roots to the bodies and spines 
of the vertebrae. Dejeriue et Thomas, Mai. d. 1. Moelle Epiniere, Paris, 1902.) 



190 



DISEASES OF THE NERVOUS SYSTEM 



Fig. 68 



cervical root leaves at the bottom of the seventh cervical vertebra, and the 
first at the top of the first cervical vertebra, or atlas. The end of the cord 
is opposite the upper border of the second lumbar vertebra. The course 
of the cervical roots in the spinal canal before their exit is very short. 
It is longer for the thoracic roots and still longer for the roots from the 
lowest portion of the spinal cord; thus, the second lumbar root has a 
course of three or four inches within the spinal canal (Fig. 68). 

Spinal Segments. — It is also necessary from the surgical point of view 
to know the relations of the different spinal segments to the vertebrae. 
This, however, is not definite and cannot be fixed by any rule, and refer- 
ence, therefore, must always be made to charts. 
It should be remembered, however, that the 
spinal cord ends opposite the upper border of 
the second lumbar vertebra, and that some- 
times in children it is a little lower. The end 
of the spinal cord is called the filum terminale. 
Functions. — The spinal cord has two func- 
tions: one, to conduct impulses to and from 
the brain; and second, in it are nerve cells 
which control the motor and trophic functions 
of the limbs, chest, and abdomen. A better 
understanding of the cerebrospinal system will 
be had if it is remembered that there are two 
sets of centres in the nervous system, and that 
in the higher, or in the cerebrum, is represented 
the centre for every motion, sensation, and 
special act, in this being included also the 
cerebellum; and that in the lower centres, in 
which are included the crus, pons, medulla, 
and spinal cord, is represented the whole sur- 
face of the body. For instance, in the crus, 
pons, and medulla there are collections of nerve cells, or nuclei, which are 
concerned with the innervation of the movements of the face, eyes, nose, 
and throat, and eating, talking, and swallowing, whereas in the spinal 
cord the collections of nerve cells in the anterior horns are concerned with 
the movements of the limbs, trunk, and abdomen, and that the peripheral 
nerves which connect the peripheral musculature with the spinal cord 
have exacdy the same function that the cranial nerves have which 
connect their musculature with the nuclei in the crus, pons, and medulla. 
Localization. — There are two enlargements of the spinal cord, the 
so-called cervical and lumbar. This is because the cells in these parts 
innervate the muscles of the upper and lower limbs respectively, the 
cervical enlargement beginning in the fourth and including the fifth, 
sixth, seventh, and eighth cervical and first thoracic segments, whereas 
the lumbar enlargement begins in the first lumbar segment and includes 
the second, third, fourth, and fifth lumbar. From here on the spinal 
cord gradually tapers off. That part of the cord which includes the 
second, third, fourth, and fifth sacral is called the conus medullaris, and 
just above this and including the fifth lumbar and first and second sacral 




Formation of a spinal nerve 
(Testut.) 



PLATE VIII 




Areas of Anassthesia upon the Body after Lesions in the Various 
Segments of the Spinal Cord. (Starr.) 

The segments of the cord are numbered: C I to VIII, D I to XII, L I to V, S 1 to 5, and these numbers 
are placed on the region of the skin supplied by the sensory nerves of the corresponding segment. 



i 



DISEASES OF THE SPINAL CORD 



191 



segments is the so-called epiconus. The nerve roots coming from the 
lumbar and sacral cords, when taken together, have been called the cauda 
equina, from their resemblance to a horse's tail. 

Motor Functions. — The nerve cells situated in the gray matter of the 
anterior horns innervate directly the peripheral musculature, and it is 
probable that a number of nerve cells are concerned with each fiber. It 
is necessary to know which cells are concerned with the innervation of 
each muscle. 



Showing the Muscles Represeiited in Groups of Cells in the Va7'ious Segments 
of the Spinal Cord. 



U. and III. 


IV. 


V. 


VI. 


VII. 


VIII. 


I. 


Cervical. 


Cervical. 


Cer\acal. 


Cervical. 


Cervical. 


Cervical. 


Dorsal. 


Diaphragm. 


Diaphragm. 












Sterno- 


Lev.ang.scap. 












mastoid. 


Rhomboid. 


Rhomboid. 










Trapezius. 


Supra- and 


Supra- and 










Scalenus. 


infraspin. 
Deltoid. 
Supin. long. 
Biceps. 


infraspin. 
Deltoid. 
Supin. long. 
Biceps. 
Supin. brev. 
Serratus mag. 
Pect. (clav.). 
Teres minor. 


Biceps. 

Serratus mag. 
Pect. (clav.). 
Pronators. 
Triceps. 
Brach ant. 
Long exten- 
sors of wrist. 


Pronators. 

Triceps. 

Brach. ant. 

Long exten- 
sors of wrist 
and fingers. 

Pect. (costal). 

Latis. dorsi. 

Teres major. 

Long flexors 
of wrist and 
fingers. 


Long flexors 
of wrist and 
fingers. 
Extensor of 

thumb. 
Intrinsic 
muscles of 
hands. 


Extensor of 

thumb. 
Intrinsic 

muscles of 

hands. 



I. Lumbar. 


II. Lumbar. 


III. Lumbar. 


IV. Lumbar. 


V. Lumbar. 


Quadr. lumb. 










Obliqui. 










Transversahs. 










Psoas. 


Psoas. 








IHacus. 


Iliacus. 
Sartorius. 
Quad. ext. cruris. 


Quad. ext. cruris. 

Obturator. 

Adductores. 


Obturator. 

Adductores. 

Glutei. 


Glutei. 

Biceps femoris. 

Semitend. 

Popliteus. 



I. Sacral. 


II. Sacral. 


III. Sacral. 


IV. and V. Sacral. 


Biceps femor. 
Semimemb. 
Ext. long. dig. 
Gastroc. 
Tibialis post. 


Gastroc. 

Tibialis post. 

Tibialis anticus. 

Peronei. 

Intrinsic muscles of foot. 


Peronei. 

Intrinsic muscles of foot. 


Sphincter ani et vesicas. 
Perineal muscles. 



192 



DISEASES OF THE NERVOUS SYSTEM 



It will be seen from this that we do not know exactly this localization 
and that approximately every muscle has a representation in the nerve 
cells of one or two segments. Should there be a lesion destroying the cells 
supplying any muscle or group of muscles, there will necessarily be loss of 
power, and as these nerve cells are also trophic in function there will be 
in addition atrophy and loss of tone or flaccidity in the related parts. 
Besides, in the performance of every movement we have a sensory irrita- 
tion or impulse, a centre for which is in the nerve cells, and a peripheral, 
or motor, response; this is the so-called reflex arc, and an interference with 
it will cause a loss of any form of reflex. Summarizing, then, the symp- 

FiG. 69 




Columns of the cord. 



toms of a lesion destroying the cells of the anterior horn, there will be 
loss of power or paralysis in the related muscles, atrophy, loss of tone, or 
flaccidity, loss of reflexes, and electrical reactions of degeneration. Such 
is the case in acute anterior poliomyelitis, or acute infantile spinal palsy. 
Should there be a slow or chronic degeneration of the cells in the anterior 
horn such as occurs in chronic poliomyelitis there will result fibrillary 
tremors in the related muscle fibers, gradual atrophy and loss of power, 
loss of reflexes, and gradual reactions of degeneration. 

The second function of the spinal cord is that of conduction of impulses 
either from or to the brain. These are transmitted by means of the 
different tracts situated in the white matter of the spinal cord (Fig. 69). 



DISEASES OF THE SPINAL CORD 193 

The motor functions are transmitted from the motor cortex by means of 
the crossed and the direct pyramidal tract. For instance, the right crossed 
pyramidal tract comes from the left motor cortex, the decussation having 
taken place in the medulla. From the pyramidal tracts these fibers 
probably go to the cells of the anterior horn of the spinal cord of the same 
side and from these cells come the anterior roots and from the anterior 
roots the motor part of the peripheral nerves. A lesion of the motor 
columns causes weakness, spasticity, increased reflexes, and the Babinski 
phenomenon. If the lesion involves the pyramidal tracts above the 
cervical cord, these symptoms are present in both the upper and lower 
limbs, but, if the lesion is below the cervical enlargement, it is only possible 
to have these symptoms in the lower limb on the same side. 

Sensory Functions. — The sensory fibers which enter the spinal cord 
by means of the posterior roots take various courses after their entrance. 
Those fibers which are concerned with touch sensation and so-called 
muscle sense ascend on the same side of the spinal cord and are first 
situated in the column of Goll and then are pushed into the column of 
Burdach by the fibers entering higher up, decussating in the medulla 
just above the motor decussation. They then go into the sensory cortex. 

Those fibers which are concerned in the transmission of sensation for 
pain and temperature enter the gray matter of the posterior horn, 
decussate almost immediately in it and travel upward in the spinal cord 
in the so-called column of Gowers. The fibers which transmit touch, 
pain, and temperature sensations after their respective decussations in 
the medulla and spinal cord are transmitted by means of the median 
fillet to the optic thalamus of the same side, and then through the posterior 
portion of the posterior limb of the internal capsule to the cortical sen- 
sory centres in the postcentral convolution of the same side. 

If a disease involves a posterior root and destroys its fibers, there will 
be loss of all forms of sensation in the parts which these fibers supply. 
The skin areas of sensation which are in relation to a posterior root are 
fairly well known and run in bands lengthwise in the limbs and in the 
chest and abdomen horizontally. It is necessary to distinguish the area 
of sensation in relation with a certain root from that of the segment 
which this root supplies. In the former the disturbance of sensation 
will always be unilateral, w^hile in a lesion involving any segment of 
the spinal cord the disturbance of sensation must be bilateral. It is 
probable that sensation in any part of the limbs or of the chest and 
abdomen is in relation with more than one root or segment and in a 
lesion which destroys only one root or segment the loss of sensation 
will be very limited. 

Bladder, Rectal, and Sexual Centres. — In the second, third, and fourth 
sacral segments are situated the centres for bladder, rectal, and sexual 
functions and a destruction of this part of the cord will cause a loss of 
these functions. It seems also that the fibers concerned with the bladder 
and rectal functions descend in the lateral columns of the spinal cord, 
and that lesions in these tracts may cause an impairment in their func- 
tions. 

13 



194 



DISEASES OF THE NERVOUS SYSTEM 



It is not the object of this chapter to discuss every disease of the spinal 
cord, but, inasmuch as tumors or injuries may involve part or all of 
the cord, it will be necessary to be able to diagnosticate a lesion in any 
part To make the subject clearer the symptoms of different diseases 
and possible lesions will be given. 



Fig. 70 




Atrophy of left upper limb and shoulder in acute anterior poliomyelitis. 

Diseases Involving the Cells of the Anterior Horn. — Acute Anterior 
Poliomyelitis. Infantile Palsy. — A disease of infancy characterized by 
sudden onset, with or without fever, flaccid paralysis of one or all of the 
limbs, followed by atrophy, loss of reflexes, and electrical reactions of 
degeneration. 

The disease usually appears in a child previously well, and rarely in the 
course of or following an infectious disease, such as scarlet fever, measles. 



i 



DISEASES OF THE SPINAL CORD 195 

or smallpox. It usually occurs sporadically, but within recent years 
epidemics have been frequent, especially in the States of Pennsylvania 
and New York. Several members of the same family, people of certain 
localities, and lower animals, such as pigs and chickens, may become 
diseased, leading to the belief that the disease is probably infectious or 
that it may be transmitted through the water or soil (Fig. 70). 

Symptoms. — The disease usually appears in the infantile period, gen- 
erally between the ages of one and three years, although it may occur 
later in life, especially in epidemics. Rarely it may occur in adults. 

It is usually ushered in by fever with its accompanying symptoms of 
malaise and chilliness, or the child may have felt sick for only a day or 
so when the weakness or paralysis is discovered. At first it is quite 
extensive and may affect all of the limbs, but, as a rule, it involves by 
preference one or both lower limbs. Within a few days to four or five 
weeks the extent of the paralysis gradually lessens and there remains 
what is called a residual palsy. The muscles of the limbs are never all 
paralyzed, but there seems to be a predilection for certain groups, as, for 
instance, in the leg, the anterior tibial and the peroneal. Because of this 
unequal paralysis contractures of various types result. The paralysis is 
always flaccid in type and it is possible to passively move the limbs. The 
cells of the anterior horn in the thoracic part of the cord are rarely dis- 
eased, this causing weakness or paralysis in the abdominal, lumbar, and 
thoracic muscles. This sometimes produces inability to sit up or to stand 
properly. Following the loss of power atrophy develops, the degree 
depending upon the extent of the destruction of the cells in the anterior 
horn. 

The tendon reflexes as well as the normal electrical reactions will be 
lost in those parts in which the reflex arcs have been destroyed or inter- 
fered with. 

Not only will there be atrophy of the muscles, but there will also be an 
atrophy of the bones of the involved limb. Because of the fact that the 
cells in the anterior horn are trophic in function, there will also be 
lessened nutrition of the skin which sometimes becomes dry and the hair 
may not grow. 

It is not at all uncommon in the onset of the disease to have a rigidity 
of the head, neck, and limbs, with pain in the back and neck and consider- 
able tenderness in the limbs. This is due to an early meningeal involve- 
ment which usually does not last very long and subsides within two or 
three days or a week. In rare instances, however, the pains may persist 
for a month or longer. There are never disturbances of sensation or of 
the bladder and rectal functions. When the disease appears in adults 
(rare) the onset and clinical symptoms do not differ from those already 
described. 

Chronic Poliomyelitis. — ^A progressive disease of the spinal cord, charac- 
terized by gradually increasing fibrillary twitchings beginning in the hand, 
with gradual atrophy, loss of power, of reflexes, of normal electrical 
reactions and contractures in the latter end of the disease resulting from 
chronic degeneration of the cells of the anterior horn of the spinal cord. 



198 DISEASES OF THE NERVOUS SYSTEM 

Syringomyelia. — A chronic disease characterized principally by typical 
dissociation of sensation, that is, ability to recognize touch with loss or 
disturbance of pain and temperature sensations, combined with atrophy, 
fibrillary tremors, weakness in the upper and sometimes in the lower 
limbs, with spasticity and exaggerated reflexes, especially in the lower 
limbs. 

The syringomyelic cavity in most instances results from lack of normal 
development of the spinal cord. Sometimes there is first an overgrowth 
of neurogliar tissue, a central gliosis, or a tumor which breaks down, 
forming a cavity. More rarely traumatism may produce hemorrhages 
into the cord, these breaking down and producing cavities. The normal 
central canal may be widened, producing what is called a hydromyelia, 
but, unless it is very large, there may be no symptoms. 

Symptoms. — The whole symptom-complex of this disease depends 
upon the interruption of the fibers concerned with pain and temperature 
sensations with preservation of touch sensation and the involvement of 
the anterior cornua and lateral columns. This is because the pain and 
temperature fibers cross over in the central gray matter, and, as the cavity 
is nearly always in this area, these functions are interrupted. If the 
cavity is limited only to the central gray matter there may be present 
only the dissociation of sensation which is referred to the related periph- 
eral part, usually in the upper limb, but in most cases the cavity also 
involves the adjacent cells of the anterior horns plus the lateral columns, 
their related symptoms developing, such as fibrillary tremors, atrophy, 
weakness, with spasticity and increased reflexes of the lower limbs. It 
can be readily seen then that the symptoms in different cases may vary. 

The disease usually begins in a young adult, the patient sometimes 
becoming aware of it by the fact that he burns himself without pain. If 
examined, touch sensation will be found to be normal, but heat or cold 
or both will not be recognized as such. Sometimes one or the other 
temperature sensation alone is disturbed, or heat may be referred to as 
cold and cold as heat. The disturbed areas are usually in the upper 
limbs, chest, and back, depending upon what spinal segments are 
destroyed. Coincident with this dissociation, or soon after, atrophy, 
tremors, and weakness in the small muscles of the hand develop, and there 
may be present a typical claw hand, its progress being very much like 
that of either progressive muscular atrophy or amyotrophic lateral 
sclerosis. Soon after there may develop weakness and spasticity of the 
lower limbs with exaggeration of the tendon reflexes and the Babinski 
phenomenon. 

The progress of the disease is usually slow and may last for twenty or 
thirty years, with gradual increase of the wasting, tremors, and loss of 
power, finally involving all of the upper limbs, shoulders and chest, 
and sometimes the lower limbs. The areas of sensory dissociation also 
gradually increase. If the cavity involves the gray matter of the lumbar 
and the sacral cord, besides the sensory dissociation in the lower limbs 
and buttocks there will be impairment or loss of bladder, rectal, and 
sexual functions, and sometimes there may be loss of the knee and Achilles 



DISEASES OF THE SPINAL CORD 197 

jerks, because of interference with the central portions of the reflex arcs. 
If the cavity extends into the medulla and pons the symptoms depend 
upon the extent of the involvement. Usually in the medulla the cavity 
is unilateral and there may be partial difficulty in eating, talking, and 
swallowing, or, if bilateral, typical bulbar symptoms develop, with tremors, 
atrophy, and weakness in the tongue, facial, masseter, and pterygoid 
muscles. If the cavity involves the sensory fibers there may be dissoci- 
ation of sensation in the face. Rarely primary optic atrophy occurs, 
and more rarely still pupillary symptoms because of involvement of the 
cervical sympathetic. 

Trophic symptoms are very common in syringomyelia. These may 
consist in different forms of skin eruption or a destruction of the joints 
either of the fingers or of the wrist and elbow or shoulder, resembling 
very much the so-called Charcot joint of tabes dorsalis. Occasionally 
there may be sharp, shooting pains in the limbs and girdle sensation. 

Diseases Involving the Motor, or Lateral, Columns. — Lateral 
Sclerosis. — Gradual weakness in the lower and then in the upper limbs, 
spasticity, increased reflexes, the Babinski phenomenon, contractures in 
the latter end of the disease, usually with the thighs adducted and flexed 
and the upper limbs in flexor contracture. 

Amyotrophic Lateral Sclerosis. — If the disease involves the lateral or 
motor columns plus the cells of the anterior horn, there will be weakness 
in the limbs, spasticity, increased reflexes, and the Babinski phenomenon, 
plus fibrillary twitchings and gradual atrophy. Contractures will come 
on in the latter end of the disease. 

Diseases of the Posterior Columns. — Tabes Dorsalis (Locomotor 
Ataxia). — A chronic progressive disease characterized first by numbness 
in the lower limbs, then by pains of a sharp, shooting character, girdle 
sensation, difficulty in walking and in execution of any movement, this 
being especially made worse with the eyes shut; absence of reflexes, 
disturbances in the functions of the bladder and rectum, irregular pupils, 
with failure of the reaction to light and later optic atrophy and dis- 
turbance of sensation in various portions of the body. 

Syphilis is probably the most important cause of tabes dorsalis, 
although rarely injuries^ especially those which cause pressure or 
destruction of the posterior roots, may cause identical symptoms. The 
pathology consists in degeneration of the posterior roots, with con- 
sequent ascending degeneration of the posterior sensory columns. There 
is nearly always an accompanying meningitis, especially in the posterior 
part of the cord. 

The disease is slow in onset, and the symptoms come on gradually over 
many years. There is nearly always first numbness in the lower limbs 
and sometimes a sensation as if walking on leather which is accom- 
panied or followed by pains of a sharp, shooting character, usually first 
described as rheumatic. The pains are not limited to one distribution, 
but appear at irregular places, and, as the disease progresses, may be 
present in all portions of the body. When referred to the viscera they 
are called crises, such as gastric, intestinal, urethral, ocular, etc. Girdle 



198 DISEASES OF THE NERVOUS SYSTEM 

sensation, or a feeling of tightness, is usually manifested around the abdo- 
men, but may be present elsewhere. The reflexes, especially the patellar 
and Achilles jerks, become diminished early, and later are lost even on 
reinforcement. The upper arm reflexes also become gradually lost. 
Inability to hold the urine, constipation, and lessening of sexual functions 
are early symptoms. 

Disturbances in sensation are prominent and can usually be demon- 
strated early and involve the deeper structures more than the superficial. 
It is characteristic that disturbances of touch and pain are nearly always 
found in the soles of the feet and the anterior portion of the legs and chest. 
The alterations in sensation are gradual and in association there is always 
loss of muscular sense, so that the patient is unaware of the position of 
his toes, feet, or limbs, this causing disturbance in locomotion and ataxia, 
which is always made worse when the eyes are closed. The disturbance 
in the gait in tabes is typical, the patient nearly always walking slowly 
with the head bent, usually with a cane, the knees are bent more than 
they should be, and the feet placed on the ground forcibly. If the patient 
should shut his eyes, he would stagger and sometimes fall. Coincident 
with the disturbance of sensation and muscle sense there is a great 
amount of hypotonia, this being manifested by the abnormal position in 
which the limbs can be placed. 

Among the early symptoms are the irregularity of the pupil, with dimi- 
nution and later loss of the iridic reflexes for light, but with motility of 
the iris on accommodation for distance, the so-called Argyll-Robertson 
pupil. Temporary oculomotor and external rectus palsy are also com- 
mon. Optic nerve atrophy, involvement of the fifth nerve, and deafness 
are occasional complications. Vasomotor and trophic disturbances are 
not unusual, and consist in occasional herpetic eruptions, disturbance of 
sweat secretions, and so-called Charcot joints which consist in an altera- 
tion in the tissues of the bones and in the articular structures, making 
it possible to move the limbs in any direction. 

Posterolateral Sclerosis. — If the disease involves the lateral and the 
posterior columns there will be weakness, spasticity, increased reflexes, 
and the Babinski phenomenon plus disturbance of touch sensation, 
ataxia, and involvement of bladder and rectum. 

Myelitis. — By this is meant inflammation of the substance of the 
spinal cord. It may be acute, subacute, or chronic; it may involve 
the whole diameter of the spinal cord when it is called transverse, or it 
may involve parts here and there when it is called disseminated mye- 
litis. It may be the result of syphilis or of an acute infection, or the result 
of an injury (Fig. 71). 

Acute Myelitis. — The symptoms of acute myelitis depend upon the 
part and extent of the spinal cord affected. Usually the dorsal region 
is most intensely involved. The symptoms may come on rapidly, some- 
times in a few hours, or may come on gradually and last for some 
weeks or months. 

When the result of an injury, the symptoms are immediate. There 
may be a feeling of malaise and even a rise of temperature, and the 



DISEASES OF THE SPINAL CORD 



199 



patient may complain of a feeling of numbness or of a tingling sensation 
in the limbs, sometimes, also, of a pain in the back. Following this, or 
perhaps without these pains, there is a feeling of weakness in the extrem- 
ities which is rapidly followed by complete flaccid paralysis. At times 
a total paralysis comes on within a few hours. Sensation in all forms 
is much affected, the upper limit of the anesthesia depending upon the 
location of the lesion. The reflexes may be lost at first, but in a short 
time the limbs will become spastic, the reflexes, such as the patellar and 
Achilles jerks, will be much increased, and the Babinski phenomenon 
obtained. The vesical and rectal sphincters are involved from the 
beginning, there being at first retention of urine and constipation fol- 
lowed by incontinence. Trophic disturbances, such as bedsores, soon 
appear. Wasting of muscles and the reactions of degeneration are 
obtained, provided the cells of the anterior horns supplying these parts 
are destroyed. 



Fig. 71 




Contracture of the lower limbs in myelitis. 



If the affection is intense, the disease extends very rapidly, soon 
affecting the cells supplying the respiratory muscles and causing death. 
If the patient survives, the course of the symptoms will depend upon the 
severity of the lesion. Usually sensation will return before motion, and 
the patient will gradually show the symptoms of spastic paraplegia. 

Myelitis Resulting from Injury. — The symptoms will resemble those 
already described with the exception that the onset is sudden, there being 
no premonitory symptoms ; and, as the destruction of the cord is nearly 
always intense, the picture may be that of a complete transverse myelitis, 
in which case there will be no return of motion and sensation in the parts 
below the point of injury. 

Serous Meningitis. — Sometimes all of the symptoms of myelitis may be 
caused by pressure due to an increase in the cerebrospinal fluid, the 
result of a serous meningitis. It is, however, impossible to recognize 



200 DISEASES OF THE NERVOUS SYSTEM 

this, for the symptoms are identical. Lumbar puncture, however, 
will demonstrate a great increase in the quantity of fluid and a heightened 
tension in the spinal canal. 

Diseases of the Spinal Roots. — Symptoms. — ^The symptoms will 
depend upon whether the anterior or the posterior roots are involved and 
upon the extent of the disease. In most instances it is impossible to tell 
whether the root or the segment of the spinal cord which the root enters 
is diseased, and it is important to remember, this when the question of 
surgical procedure is considered, for it will then be necessary to expose 
not only the spinal segment which the root supplies, but the whole extent 
of the root in the canal. In such instances it is advisable always to 
expose first the exit of the root and go upward. 

In the differential diagnosis between a root and segment lesion, it is 
noted that in the former the symptoms are more liable to be referred to 
definite parts. In the latter they will be diffuse and involve the distri- 
bution of other roots, for a lesion of the cord itself is hardly ever unilateral. 

Anterior Root Lesions. — As the anterior roots are motor there will be 
fine tremors or twitchings in the corresponding muscle fibers, to be fol- 
lowed by paralysis when the root is destroyed. If the lesion extends 
farther into the spinal cord, the symptoms of this will be apparent. 

Posterior Root Lesions. — These are more common. As the posterior 
roots are sensory in function, any lesion will first give irritative phenomena, 
such as numbness and paresthesia in the skin distribution related to these 
roots, to be followed by pains of a lancinating character or girdle sensation, 
and, if the roots are destroyed, anesthesia in the related parts. There 
will of course be secondary degeneration in the columns of Goll and 
Burdach. 

Unilateral Spinal Cord Lesions, or Brown-Sequard Paralysis.— 
Sometimes tumors or injuries resulting from bullet or stab wounds will 
cause a unilateral lesion of one or two segments of the spinal cord. 
The symptoms will depend upon the part of the cord involved and the 
extent of the lesion. Should there be, for instance, a unilateral lesion in 
the eighth cervical and first thoracic segments of the right side of the cord, 
there will be the following symptoms : Because of the destruction of the 
nerve cells in the anterior horns, inability to flex or extend the right wrist 
or move the fingers, besides atrophy and electrical reactions of degen- 
eration in these parts. Because of the involvement of the right motor 
or pyramidal column, weakness, spasticity, increased reflexes, and the 
Babinski phenomenon in the right lower limb. Because of the destruc- 
tion of the sensory roots, loss of all forms of sensation along the under 
surface of the whole right arm. As the posterior columns transmit the 
fibers for touch sensation and muscle sense there will be disturbance of 
touch in the right lower limb and right abdomen and chest, with impair- 
ment of muscle sense and ataxia in the right leg. In the left lower limb 
there will be disturbance of pain and temperature sensations only, 
because of the destruction of the right column of Gowers. 

Influence of Secondary Degenerations. — ^Whenever there is a lesion in 
any portion of the spinal cord there will necessarily be secondary degenera- 



DISEASES OF THE MENINGES 201 

tion. If the motor columns are involved, the degeneration will be down- 
ward; if the sensory, upward. Secondary degenerations do not cause 
active symptoms, for whatever first produced the original lesion has also 
caused the secondary degeneration, and this is no more than a mechanical 
death of the part. 

DISEASES OF THE MENINGES. 

The meninges, which envelop both the brain and spinal cord, are 
divided into the outer coat, or the dura, and the inner, or the pia and 
arachnoid. Inflammation of the dura is called pachymeningitis, and of 
the inner coats leptomeningitis. With the exception of localized inflam- 
mations and those following injury, inflammation of the meninges nearly 
always involves the coverings of both the brain and spinal cord. 

Cerebral Pachymeningitis. — This may affect either the outer or the inner 
coat, when it is called external or internal pachymeningitis. External 
pachymeningitis nearly always results from injury to the skull, and is not 
so common as is usually thought. It may be secondary to a growth of 
the overlying bone, especially in syphilitic, tuberculous, or carcinomatous 
conditions. 

Internal pachymeningitis is rare. It sometimes is hemorrhagic in 
nature, there being accumulations of blood between the dura and pia, 
and usually occurs in old persons, especially in those who are either 
arteriosclerotic or alcoholic. It is rarely found in some forms of insanity. 
It may be present in conjunction with external pachymeningitis, especially 
in purulent, syphilitic, or tuberculous inflammation. 

Symptoms. — The symptoms of pachymeningitis, whether external or in- 
ternal, are indefinite and depend upon the pressure exerted upon the brain. 
Generally the patient complains of headache and, rarely, of tenderness 
localized to the inflammatory area, the specific symptoms depending 
upon the part of the brain involved. If in the motor area, there will be 
irritative symptoms, such as Jacksonian convulsions, which may be 
followed by greater or less paralysis; if over Broca's convolution, motor 
aphasia; if over the parietal areas, where pachymeningitis is most 
common, there may be irritative pains or paresthesia on the other side 
of the body, accompanied sometimes by disturbance of sensation; if over 
the temporal lobes, aphasia; if over the occipital convolutions, disturbance 
of vision on the other side. There may Sometimes be loss of conscious- 
ness, delirium, or stupor, or there may be no symptoms at all. 

Spinal Pachymeningitis. — Isolated inflammation of the spinal dura 
without involvement of the membranes underneath is very unusual and 
hardly ever occurs. In some instances, however, the dura is preponder- 
antly involved. As a rule, inflammations of the dura are secondary to 
disease of the vertebra, as in tuberculous, syphilitic, carcinomatous, or 
sarcomatous lesions. It is possible to have a syphilitic pachymen- 
ingitis w^ithout involvement of the vertebra, but in most of these cases 
the pia and spinal cord are also diseased. The symptoms of a spinal 



202 DISEASES OF THE NERVOUS SYSTEM 

pachymeningitis secondary to vertebral inflammations will be discussed 
under the latter heading. 

Inflammation of the Pia Arachnoid. — Cerebrospinal Meningitis. — 
In most cases the pia of the brain and spinal cord are involved at the same 
time, and it is only rarely that either is involved alone. Inflammations 
may be of various kinds. The other varieties are purulent, tuberculous, 
and serous. 

Syphilitic meningitis has been discussed under the head of Syphilis 
(p. 166). 

Purulent Meningitis. — In most instances purulent inflammation of the 
meninges is secondary to septic processes elsewhere, such as infected 
wounds of the scalp or cranium, sinusitis, middle ear disease, localized 
abscess of the brain or pia, and general pyemic processes or ab- 
scesses in the various parts of the periphery; or secondary to a septic 
endocarditis or one of the infectious diseases, as pneumonia or typhoid. 
As a rule, the process involves equally the membranes of the convexity, 
base of the brain, and spinal cord. 

Symptoms. — If the meningitis occurs in the course of an infectious 
disease, as typhoid, pneumonia, septic endocarditis, or is secondary to 
pyemic processes, injuries to the head, or middle ear disease, their accom- 
panying symptoms will be present, and very often the early symptoms of 
meningitis are masked. As a rule, they come on rapidly with headache, 
which at times is excessive, and a rise of temperature, the patient be- 
coming delirious, stuporous, and then unconscious. The pulse generally 
at first is rapid and then slow and somewhat irregular, and respiration 
becomes more or less embarrassed. The head is retracted, the back 
held rigidly, and often the patient assumes a position of opisthotonos. 
The arms are retracted, the legs are flexed on the abdomen, and any 
attempt to extend the legs with the thighs flexed is met with resistance 
(Kernig's sign). About this time the irritative phenomena become 
prominent, and there may be general convulsions, or the spasms may 
be limited to one or more limbs, and be followed by partial paralysis 
or hemiplegia. The reflexes may be exaggerated, diminished, or lost. 
Because of basilar involvement the pupils become irregular, their 
reactions impaired, and there may often be swelling of the optic nerve 
heads, or choked disk„ Cranial nerve palsies are common, especially 
of the sixth, causing diplopia; the third, resulting in ptosis of the upper 
lid and inability to move the eyeballs; the seventh, paralysis of the face; 
and of the vagus, interference with the action of the cardiac and 
respiratory functions, and ultimately death. Vasomotor phenomena 
may be present consisting in a flushing of the skin after stroking, or 
tache cerebrale. 

Tuberculous Meningitis. — In this type the inflammation is nearly 
always confined to the membranes of the base of the brain, although there 
is some involvement of the convexity. In nearly all cases the tuberculous 
meningitis is secondary to similar processes elsewhere, especially of the 
lung, intestines, or glands. It may occur in adults, but in most instances 
it affects children below the fifth year. 



DISEASES OF THE MENINGES 203 

Pathologically there is found tuberculous inflammation, with small 
miliary nodules, and there is nearly always some serous effusion. 

Symjptoms. — When occurring in an adult, there are nearly always the 
accompanying symptoms of a tuberculous inflammation elsewhere, either 
in lung, pleura, or glands. There gradually develops headache, irrita- 
bility, vomiting and nausea, rigidity of the head and neck, some disturb- 
ance of consciousness, and then the symptoms of involvement of the 
cranial nerves at the base of the brain. These are choked disk, or optic 
neuritis; irregular pupils, with disturbance of their reactions; ocular 
palsies, drooping of the upper lid; facial paralysis; disturbance of hearing 
and of cardiac and respiratory functions. Sometimes there may be con- 
vulsions or paralysis of the limbs of one or both sides. In most instances 
the disease is fatal. 

Tuberculous Meningitis in Infants. — When it occurs in infants there is 
usually a slow onset with general restlessness, loss of weight, rise of 
temperature, and gastro-intestinal disturbances with delirium, uncon- 
sciousness, and retraction and rigidity of the head, neck, and back, 
retraction of the upper and lower limbs, and the symptoms of basal 
involvement which have been described above. Usually the disease 
terminates in death, but, if the patient lives, there will be closure of some 
of the ventricular connections with a consequent internal hydrocephalus. 
Because of this there will be an increase in the size of the head, bulging 
of the fontanelles, paralysis of one or both sides of the body, impairment 
of intellect, and a general rachitic condition of the body with its accom- 
panying symptoms of maldevelopment. 

Serous Meningitis — Meningism. — This is a form of meningitis only 
recently described in which there is an effusion into the meninges, but 
in which there is no exudation such as occurs in the purulent variety. 

Under the ieTm.meningism,meningismus, or pseudomeiiingitis has been 
described that clinical variety in which the symptoms of meningitis are 
present, but in which pathologically and by lumbar puncture nothing is 
found beyond a congestion and edema of the vessels. It is probable 
that it is nothing more than the primary stage of a serous meningitis. 
If the disease goes farther, or into the second stage of effusion, there will 
be what is commonly termed serous meningitis. 

Meningeal processes, whether of an irritative or of an effusive nature, 
can be likened to similar pathological conditions occurring in the internal 
organs, as in the various stages of a pleurisy or pericarditis. 

Pathologically, in meningism there will be found a congestion of the 
bloodvessels with either little or no edema, and rarely the germ of the 
disease may be found in the meninges. In serous meningitis a similar 
condition is present, with the addition that there will be a serous effusion 
with an increase of the lymphocytic elements, and only rarely will a 
specific organism be found. 

Symptoms: Meningism. — This may occur in the course of or follow 
any infectious disease, such as pneumonia, typhoid, rheumatism, scarlet 
fever, measles, or la grippe. It is not difficult to recognize, for there will 
be present those symptoms which are commonly termed meningeal, such 



204 DISEASES OF THE NERVOUS SYSTEM 

as pain along the back or limbs which may be of a numb character or 
may be decribed as sharp and shooting, but the principal complaint is 
headache, especially in the back of the head. Besides, there will be 
rigidity of the head and back, and unwillingness to move the limbs be- 
cause of fear of increasing the pain. Sometimes there will also be hyper- 
esthetic areas in different parts of the body. There may rarely be mus- 
cular twitchings in the limbs and a general increase of the reflexes. 
Lumbar puncture is negative. The onset is generally acute. The 
temperature may or may not be increased, and the pulse and respiration 
are not much altered. The duration of the disease is usually short and 
the prognosis always favorable. Sometimes, however, there may be a 
complicating serous effusion. 

Serous Meningitis. — ^This may involve either the brain or spinal cord 
alone, or both. There will be in addition to the symptoms enumerated 
above, which may occur first, pressure symptoms resulting from the 
presence of fluid, their intensity depending upon the degree of the pressure. 
When the spinal cord is principally involved, there will be, in addition 
to the meningeal symptoms, pains in the limbs, girdle sense around 
the waist, and, because of pressure upon the anterior and posterior roots 
and later on the spinal cord, disturbance of sensation, increased reflexes, 
which are later lost, and bladder and rectal disturbances. Lumbar 
puncture will always demonstrate an increase in the intraspinal pressure, 
and there will be considerable exudation of fluid. In most cases the 
disease lasts only a few weeks, the patient getting well. 

In the cerebrospinal forms, besides the symptoms enumerated, there 
will be some disturbance of consciousness and greater rigidity of the 
head and neck and of the limbs, and sometimes a swelling of the optic 
nerve heads. More rarely there may be tempoi'ary diplopia and dis- 
turbances in the temperature, pulse, and respiration. Lumbar punc- 
ture will, of course, demonstrate increased intraspinal pressure with 
increase of fluid. In most instances the symptoms will subside in a 
few weeks, the patient getting well. If, however, they persist, there will 
develop a serous effusion in the cerebral ventricles with its accompany- 
ing symptoms of intraspinal pressure. 

Cerebral Serous Meningitis. — A serous effusion into the ventricles 
may be the beginning of a general serous meningitis, or may be confined 
only to them. The same causes which are active in the production of 
a serous meningitis may produce an internal hydrocephalus. 

Pathologically there will always be found an internal and sometimes 
also an external hydrocephalus, or an increase of fluid in the cortical 
meninges. Histologically there may be cloudy swelling and prolifera- 
tion of the ependyma, accumulation of cells under the ependyma, and 
cellular infiltration in the brain and spinal cord substance and in its 
meninges, especially along the bloodvessels. The choroid plexus is 
nearly always diseased, and its overaction is supposed to be the cause 
of increase in fluid. 

Internal hydrocephalus resulting from serous effusion, as a rule, comes 
on in early childhood and is not diflficult to recognize if the process is 



TUMORS OF THE SPINAL CORD 205 

active. Very often, however, there may be only mild symptoms, such as 
have been described under meningism, only to have later in life either an 
acute or chronic serous meningitis or internal hydrocephalus. In fact, 
many writers consider that serous meningitis or serous effusion in the 
ventricles in the adult is only an acute exacerbation of an old process 
which had its origin in childhood. However that may be, there is no 
question that in the adult a serous effusion may develop in the ventricles 
either acutely or gradually and cause symptoms which are usually 
recognized as occurring in brain tumor, and from which it is sometimes 
almost impossible to make a differential diagnosis. 

If internal hydrocephalus develops acutely there will be, as a rule, an 
accompanying high fever and the course of the disease will be rapid, it 
resulting either in cure or death. Headache, nausea, vomiting, vertigo, 
and disturbance in vision and choked disk, sometimes marked, are 
prominent symptoms. Besides, there may be paralysis of some of the 
cranial nerves, especially of the sixth, either on one or both sides, and 
there may also develop cerebellar ataxia. Consciousness is nearly 
always clouded. The disease may last a week or two, terminating in 
quick recovery, leaving behind slight atrophy of the optic nerves, but 
no other symptoms. Sometimes there may be a recurrence of the disease, 
this terminating also either in recovery or death. The diagnosis from 
a brain tumor can usually be made by the rapid onset, high fever, and the 
quick recovery or termination in death. 

If, however, the symptoms of internal hydrocephalus come on gradually, 
the differential diagnosis from brain tumor will be very difficult. There 
will be present all the pressure symptoms, such as headache, nausea, 
vomiting, vertigo, and choked disk, and, because of the pressure exerted 
upon the motor fibers in the internal capsule, there will result weakness 
and spasticity of the limbs with increased reflexes and sometimes the 
Babinski reflex. There may also be paralysis of the external rectus, 
either on one or both sides. Because of pressure on the cerebellum there 
will result incoordination in walking and sometimes incoordination of the 
eyeballs, or nystagmus. The differential diagnosis from cerebellar lesions 
is sometimes very difficult, but can be made principally upon the fact 
that in cerebellar tumors there is hardly ever involvement of the limbs 
on both sides and the ataxia is more acute and much more marked. 

It must also be remembered that internal hydrocephalus may also 
accompany tumors either of the cerebrum or cerebellum, and in such 
case there will be, in addition to the symptoms resulting from the tumor, 
spastic paresis of the limbs with increased reflexes and the Babinski 
phenomenon. The prognosis in most cases of uncomplicated internal 
hydrocephalus is not very good, but sometimes complete recovery ensues 
either as a result of operative interference, antisyphilitic treatment, or 
sometimes spontaneously, leaving behind nothing but a slight atrophy 
of the optic nerves. 

Tumors of the Spinal Cord. — In comparison with tumors of the brain 
they are rare and may be extradural, intradural, or involve the spinal 
cord itself. They are mostly intradural, tumors of the cord being 



206 DISEASES OF THE NERVOUS SYSTEM 

most rare. Pathologically they may be sarcoma, fibroma, glioma, car- 
cinoma, or cystic. Tuberculous and such other tumors, as psammoma, 
myxoma, endothelioma, and lipoma, rarely occur. 

Sarcoma. — Sarcoma of the cord itself is rare and is secondary to that 
of the vertebra, when it involves the anterior and especially the posterior 
roots or may infiltrate in the pia. Generally the lower portion of the 
spinal cord, especially the cauda equina, is the seat of multiple sar- 
comata. Their characteristics have already been discussed, and it 
need only be remembered that sarcomata may be soft and infiltrating, 
and, because of this, may give only a few symptoms. 

Fibroma. — These tumors are mostly intradural and grow in the pia 
or about the roots. As a rule, they are not multiple, and are favorable 
for operative removal. 

Cysts. — These may be limited to the meninges and be simple or may 
be multiple, as occurs in cysticercus cellulosse and in echinococcus cysts. 

Symptoms. — These will depend upon the location of the tumor and 
extent of the involvement, either of the meninges, root, or cord. As a rule, 
most tumors are located in the thoracic cord and are generally situated 
about the lateral and posterior surfaces. It is impossible to state defi- 
nitely what symptoms may occur in tumors, but they are either due to 
involvement of the roots or the spinal cord itself. 

Root Symptoms. — Numbness or pain or girdle sensation to be followed 
by pain are usually among the first manifestations, these being referred 
to the parts in relation with the posterior root diseased. As a rule, the 
pains are sharp, shooting, and agonizing in character and may be of such 
intensity as to prevent the patient from moving. If the growth involves 
several posterior roots and is large, there may be tenderness and pain on 
pressure over the involved part, and jarring may sometimes cause excru- 
ciating pains. Later, there may be an accompanying disturbance of 
sensation. 

Cord Symptoms. — As the spinal cord itself becomes involved its accom- 
panying symptoms will develop, such as disturbance of sensation if the 
posterior part of the cord is affected, and, if the lateral columns are com- 
pressed, there will be weakness, spasticity with increased reflexes, and the 
Babinski phenomenon in the parts below. Of course, if the tumor is 
around the anterior part of the cord the symptoms will be purely motor. 
This, however, is uncommon. 

Tumors of the Cauda Equina. — These are generally sarcomatous and 
multiple. The symptoms will depend upon what roots are involved. 
There will usually be pain referred to the sciatic distribution of one or 
both sides, or possibly a localized pain in the lower part of the back, but 
the most distinguishing feature is the segmental disturbance of sensation 
around the buttock, perineum, anus, and in the genital organs. There 
may also be disturbance of the bladder, rectal and sexual functions. 
Paralysis is not very common, but, if it occurs, will usually be in the 
distal portions of the limbs. 

Tumors of the Vertebra. — These are generally sarcoma or carcinoma, 
or may be the result of a growth of the bone tissue, when they are called 



INJURIES OF THE SPINAL CORD 



207 



myelomata. The earlier mentioned tumors are nearly always secondary 
to growths elsewhere, generally from the lungs, stomach, breast, prostate, 
or uterus. Such benign growths as osteoma or enchondroma may some- 
times occur. 

Root and Spinal Cord Symptoms. — ^As the disease progresses pressure 
will be first exerted on the posterior roots, and the first symptoms will be 
those of numbness, to be followed by sharp, lancinating pains, with girdle 
sensation, referred to the distribution of the diseased roots. Any jarring 
of the back or pressure will bring on a fresh attack or exaggeration of 
pain. As the disease involves the dura and the cord, there will be added" 
disturbance of sensation and of bladder and rectal functions, weakness 
in the limbs, with increased reflexes, spastic condition, and the Babinski 
phenomenon. The extent of the paralysis will of course depend upon 
the amount of involvement, there sometimes resulting complete myelitis 
and total paralysis (Fig. 72). 



Fig. 72 




Diffuse myelitis resulting from pressure of carcinomatous tumor of the vertebra. 

Injuries of the Spinal Cord.— The result of any injury, no matter 
how trivial, cannot be foretold. There may be, first, a sprain or injury to 
the ligaments of the vertebral column, either with or without injury of 
the cord; second, fracture or dislocation of the vertebra, or both, either 
with or without involvement of the spinal cord; third, injuries to the 
cord itself; and lastly, the so-called traumatic neuroses which may 
enter into all of the above classifications and also are independent of 
these. The symptoms will be discussed in order. 

Sprain or Injury to the Ligaments of the Vertebral Column, with or without 
Involvement of the Cord. — This generally results from overstretching 
of the vertebral column or from some severe muscular effort. A direct 
injury to the back may cause a contusion of the ligaments. As a rule, 



208 



DISEASES OF THE NERVOUS SYSTEM 



the cord itself will not be involved, and the symptoms will be those of 
pain localized to the affected parts, with accompanying rigidity of the 
back and pain on movement. There should be no difficulty in making 
this diagnosis were it not for the fact that in some cases there may be 
present the symptoms of a traumatic hysteria which may resemble 
injury of the cord, or there may be what not infrequently occurs, multiple 
small hemorrhages or areas of softening in various portions of the cord, 
and sometimes hemorrhages into the substance. Their symptoms will 
be fully discussed. 





Fig. 73 




M[^^ vi*^^^^ 


^^ci^: 




/ 




I 


n; 




J'^ 


„,. ,J', ^^. .^ 


' >- r'-^i^sa," 


j^wW 



Section of spinal cord, showing diffuse small hemorrhages and one large hemorrhage in one 
posterior horn resulting from injury to the spinal cord. The section is taken two segments 
above the injury. 

Injuries to the Cord. — In nearly all cases where the injury has been 
severe enough to cause a fracture or dislocation of the vertebra the cord 
itself will be severely damaged. This may be either because of a direct 
pressure exerted upon the cord, the result of forward displacement of 
the vertebra, or as sometimes happens there will be at the time of injury 
a sudden torsion or twisting of the spine, this causing momentary press- 
ure upon the cord, with destruction of its elements. Again, there may 
be severe injury to the cord, with either multiple small hemorrhages or 
softening or one large hemorrhage, but no evidence of fracture or dislo- 
cation or even sprain or contusion of the ligaments (Fig. 73). 

The symptoms of compression of the cord will not differ from those 
described under the head of myelitis. As a rule, the destruction will be 
intense, and transverse myelitis and sometimes complete severance of 
the cord will result, this causing complete loss of power and of sensation 
in the parts below, with bladder, rectal, and trophicsymptoms. It must 



INJURIES OF THE SPINAL CORD 



209 



also be remembered that besides the direct destruction of the cord, the 
result of the injury, there will also be multiple small areas of hemorrhage 
above and below the point of injury. If there is only a partial destruc- 
tion, there will be, after the initial complete paralysis of motion and sensa- 
tion, return of sensation, and then of motion, with increased reflexes, spas- 



FiG. 74 




Photograph showing complete bilateral foot drop with contracture and trophic changes in 
case of myelitis resulting from injury to the cord. 



Fig. 




Backward dislocation of fifth cervical vertebra resulting from a fall, causing pressure upon 
the spinal cord, with partial paralysis of the upper limbs and to a less extent of the lower. 

ticity, Babinski phenomenon, and disturbance of bladder and rectal 
functions. 

Hemorrhages into the cord, or hematomyelia, may occur with contusion 
of the substance of the cord or independently of this as a result of injuries 
14 



210 



DISEASES OF THE NERVOUS SYSTEM 



Fig. 76 



without an accompanying fracture or dislocation of the vertebra. As a 
rule, hemorrhages occur into the substance of the cord mostly in the 
central gray matter, and only very rarely in the outer or inner surface 
of the dura. The gray matter of the cord seems to be easier to infiltrate 
than the white matter, and as a consequence any hemorrhage may 
involve considerable length of the cord. The symptoms will depend 
largely upon the location of the lesion, whether within the cervical, 
thoracic, or lumbar parts, and upon its extent. As the hemorrhage 
involves principally the middle portion of the cord, it will interrupt the 

fibers concerned with transmission of 
pain and temperature sensations, and 
there will result the so-called syringo- 
myelic disturbance of sensation in the 
lower limbs, i. e., loss of pain and tem- 
perature sensations with preservation 
of touch. Besides, there will be weak- 
ness with spasticity, increased reflexes, 
and the Babinski phenomenon, and, if 
the hemorrhage involves the cells of 
the anterior horn, loss of power with 
atrophy and reaction of degeneration 
in the related parts. 

If, however, there should be multiple 
microscopic areas of hemorrhage or 
softening, no definite symptoms will 
result, because there has not been suffi- 
cient injury to cause disturbance in 
function unless the injury occurs where 
marked arteriosclerosis is present, when 
severe hemorrhages or softening may 
be brought on any time through the 
weakening of the vessel walls (Fig. 74). 
The Prognosis of Injuries of the 
Spinal Cord. — ^This will depend upon 
the nature and the extent of the 
injury. If the cord has been 
severely crushed for several seg- 
ments, there can be no hope for 
return of function. If the injury has been partial, some return of power 
will always result. If a hemorrhage has occurred in the central gray 
matter, there should be some return of power, and if multiple microscopic 
areas of hemorrhage or softening, complete recovery may ensue. In 
all these instances the prognosis depends entirely upon the possible 
regeneration of fibers in the spinal cord, and this has been the subject of 
controversy for a long time. It is probable that this cannot occur, 
and improvement results because the fibers which have been injured 
have recovered from whatever traumatism they had been subjected 
to. In every injury there is a certain amount of shock which will tem- 




Partial dislocation of the second and 
third cervical vertebra due to injury, 
showing attitude and rigidity of the head 
and neck. 



TRAUMATIC NEUROSES 211 

porarily injure the cord but, unless a complete severance or myelitis 
ensued, there should nearly always be some return of function. 

Spina Bifida. — A defect in the closure of the posterior vertebral arches, 
especially in the lumbar and the sacral region. It is of embryonal origin 
and is usually detected at birth or very soon after, and, rarely, may inter- 
fere with it. The defect may consist only in a lack of union of the posterior 
vertebral arches, but, as a rule, there is a tumor-like projection in the 
lower spine which may consist only in a protrusion of the dura, and which 
may be from the size of a nut to that of an orange or larger and be filled 
with cerebrospinal fluid ; or there may be in connection with the dural 
protrusion an involvement of the spinal cord itself, consisting either in 
an enlargement of the central canal, a hydromyelia, or attachment of the 
lumbosacral cord or its roots to the walls of the sac. 

Symptoms. — Most cases of spina bifida die either at or soon after birth. 
When there is only a dural involvement, there may be no symptoms 
except the physical evidences of the protrusion. Pressure, however, 
upon the sac will cause bulging of the fontanelles with the symptoms of 
cerebral compression. If, however, the cord itself be involved, there will 
be paralysis of both lower limbs and disturbance of bladder and rectal 
functions and of sensation. The disease is of long duration, the symp- 
toms having a tendency to increase, and the prognosis is not very good. 
There are frequently in association embryonal defects elsewhere, such as 
cleft palate or harelip. 

Traumatic Neuroses. — Under this head will be discussed the so- 
called traumatic neurasthenia, hysteria, and hysteroneurasthenia which 
occur as the result of injuries to any part of the body, especially to the 
head and back. No matter how trivial the injury or what part of the 
body has been injured, there may be a certain amount of accompany- 
ing shock, and, even in those cases where the injury has produced 
unconsciousness this may occur afterward. It can be seen, then, that 
in every case of injury there may be a certain amount of so-called 
neurasthenia or hysteria, and the repeated examinations by physicians 
and the constant attention paid to the patient during the process of 
litigation may tend to increase and cause new symptoms. It is 
important from the standpoint of the patient to settle the case as soon 
as possible. 

Traumatic Neurasthenia. — ^This is generally produced by injury to the 
back or head, or may follow injuries to other portions of the body. It 
may also be due to such other causes as fright, the result of lightning 
and other physical or mental shock. It must be remembered that the 
symptoms of neurasthenia may be entirely in disproportion to the extent 
of the injury, for sometimes the most trivial cause may produce the 
greatest number of symptoms, and vice versa. The symptoms of trau- 
matic neurasthenia do not differ from those the result of other conditions. 
They are subdivided into mental, sensory, motor, and special. 

Mental Symptoms. — ^The patient at the time of the injury may not 
have any mental shock, may be badly frightened, or be unconscious. 
Very often the patient who does not suffer the slightest perturbance at 



212 DISEASES OF THE NERVOUS SYSTEM 

the time of the accident may become the worst neurasthenic, and in 
nearly all cases the impression of the accident will remain for some time 
and will be the dominant topic of thought and conversation. To this 
may be added the fear of having sustained a severe and irreparable injury. 
In a short time the patient will be chiefly or entirely occupied in thinking 
of his accident and of his symptoms to the exclusion of every other topic. 
Because of this he will complain of loss of memory, of inability to attend 
to details of business, and insomnia, but the greatest trouble will be that 
every little symptom will be exaggerated. This mental condition may 
last for some time, especially if litigation is prolonged, but under proper 
care most cases should get well. 

Sensory Symptoms. — Pain along the back is one of the commonest 
symptoms, especially if the spine has been injured. It is generally 
described as dull and aching, and sometimes it is located in the lower 
portion of the back, when it will have the characteristics of lumbago. 
Any pressure over the painful spots or bending of the body will increase 
the pain. 

Headache is very frequent and is generally in the back of the head 
and neck, and sometimes radiates into the frontal region. It is usually 
described as dull and aching with occasional exaggerations. Sometimes 
the patient will complain of pains of a numb character in the limbs, and 
often this is accompanied by pain on pressure over all parts of the body. 

Motor Symptoms. — Physical weakness is one of the commonest and 
most constant manifestations of neurasthenia, the patient complaining 
of exhaustion and of inability to perform repeated muscular efforts. On 
testing such a patient it will be found that the grip or resistance against 
movement may be strong at first, but that the patient is easily exhausted. 
The reflexes will generally be increased, and very often there may be 
irregular tremors all over the body of a fibrillary or of a coarser character. 

Special Symptoms. — Pain in the eyeballs with dimness of vision and 
inability to read for any length of time is a very common symptom, as 
is also some diminution in hearing. Loss of appetite, nausea, vomiting, 
and constipation are also very frequent. 

Traumatic Hysteria. — ^The same causes which are productive of neu- 
rasthenia will also produce hysteria. While neurasthenia is considered 
as being due to an alteration of function produced by fatigue or exhaus- 
tion, hysteria is probably more the result of a cerebral disturbance because 
the symptoms of it are such as may result from cerebral lesions. It is 
probable that the two conditions are identical, and that in hysteria we 
have the severest form of the affection. The symptoms may be sub- 
divided similarly to those of neurasthenia. 

Merital Symptoms: — What has been said of the mental symptoms 
occurring in traumatic neurasthenia will also answer for those of trau- 
matic hysteria, only in hysteria the patient is much more impressionable 
and the symptoms are generally more marked and numerous. 

Sensory Symptoms. — Here, as in neurasthenia, backache and headache 
and diffuse pains in all parts of the body are very common. It is not 
unusual to find that the patient has diminution or loss of sensation for 



TRAUMATIC NEUROSES 213 

touch, pain, and temperature over a part of a limb, a whole limb, or one- 
half of the body, and sometimes of all parts of the body. 

Instead of diminution of sensation there may be a hyperesthesia. This 
is generally over certain spots, as over the back of the head, neck, and 
spine, and in the inframammary, ovarian, and inguinal regions and some- 
times over the limbs. 

Motor Symptoms. — Here, as in neurasthenia, the dominant symptom 
will be that of fatigue and easy exhaustion with muscular tremors and 
increase of the tendon and skin reflexes. Besides, there may be paralysis, 
which may involve a part of a limb, a whole limb, or a half of the body, 
giving the symptoms of a monoplegia, a hemiplegia, and more commonly 
still there may be a paralysis of both lower limbs simulating paraplegia. 
It is important to diagnosticate these from organic lesions. We may have 
in hysteria the usual mental and sensory symptoms, but it must be 
recalled that these may also accompany an organic lesion; the differen- 
tial diagnosis must be made upon the onset, character, and symptoms of 
the paralysis. It will be found that the onset is more or less sudden and 
not commensurate with the extent of the injury, that the paralysis is not 
complete, and that when the patient is taken off guard considerable 
power may be manifested. Again, while there always will be a general 
increase of tendon reflexes and sometimes an ankle clonus, the Babinski 
reflex never occurs in hysteria. Besides, the patient is always amenable 
to suggestion, and even an increase in the paralysis may be brought about. 

Contractures may sometimes result in a limb, either accompanying an 
hysterical paralysis or without this. The contractures are usually not 
of the regular type, and, if general anesthesia is induced, complete flac- 
cidity will result. 

Tremors are not unusual and occur in various portions of the body 
or only in one limb, when they may be of the most violent character and 
usually out of proportion to the injury, and are accompanied by the usual 
hysterical symptoms. Sometimes convulsions may result. These may 
be partial or general and may resemble closely an epileptic attack. A 
differential diagnosis, however, can always readily be made by the fact 
that in hysteria there will not be the history of attacks occurring in child- 
hood, there will be no aura or preliminary cry, the patient will never hurt 
himself, and there will be no biting of the tongue or voiding of urine. 
Besides, the movements will not have the regular clonic-tonic succession, 
they being mostly wild and irregular, and most important of all, uncon- 
sciousness will not result. Attacks may be brought about by any emo- 
tion, and are generally prolonged for a number of minutes and sometimes 
for hours. 

Special Symptoms. — Pain in the eyeballs and visual irritability and 
fatigue when reading are very common symptoms. Sometimes to this are 
added such irritative phenomena as flashes of light and spots of various 
kinds which appear in the field of vision. In grave cases there may be 
diminution in the fields of vision of one or both eyes which may or may 
not be homonymous, and at times there may be complete hemianopsia 
and reversion of the color fields. 



214 DISEASES OF THE NERVOUS SYSTEM 

Diminution, loss or hyperacuity of hearing sometimes occurs. There 
may also be perversion in taste and smell or loss of these senses. Dis- 
turbances in gastric, bladder, and rectal functions are not infrequent 
symptoms. 

Traumatic Hysteroneurasthenia. — In the majority of cases the symp- 
toms both of hysteria and neurasthenia occur, and only very rarely do v^e 
have either condition alone. It will not be necessary to give the symp- 
toms of hysteroneurasthenia, as these have already been sufficiently 
discussed. 

DISEASES OF THE PERIPHERAL NERVES. 

Only those nerves which are commonly injured or diseased will be 
considered. Any motor or sensory nerve may be inflamed, constituting 
neuritis. By neuralgia is meant an inflammation of a sensory nerve 
only, whether this be peripheral or cranial. There are many causes 
for neuritis and neuralgia, many of these being constitutional disturb- 
ances, local causes, contusions, and injuries; but a large number of 
diseases of the nerves come on apparently without any cause, at least 
no cause can be found by the microscope, and are thought to be func- 
tional in origin. 

Every peripheral nerve consists of an axis cylinder, of an enveloping 
substance called myelin, and of a sheath which surrounds the myelin 
substance called the neurilemma. The nerves in the brain and spinal 
cord do not have this sheath, and those of the sympathetic system 
also do not contain it nor are they surrounded by myelin substance. 
Regeneration will occur in every peripheral nerve. 

Inasmuch as the function of every peripheral and cranial nerve is 
concerned either with motion, sensation, or with both, the symptoms must 
depend upon what nerve is diseased. If a motor nerve, there will be 
paralysis; if sensory, disturbance of sensation, this being manifested by 
numbness, a tingling feeling, or pin and needle sensation or by pain, and, 
if the nerve is destroyed, by anesthesia. As most nerves are both motor 
and sensory there will be both paralysis and disturbance of sensation. 
There will, besides, be such trophic phenomena as disturbance in skin 
secretions, with either excess or absence of sweating, drying of the skin 
and nails, and falling out of the hair. If a motor nerve is diseased 
there will also be electrical reactions of degeneration and loss of reflexes. 

Reactions of Degeneration. — A normal nerve or muscle will respond to 
any form of electrical stimulation. If it is diseased, it will not respond 
to a faradic current, but will give an increased and prompt response to a 
galvanic current, and the reaction obtained will be slow and sinuous in 
contrast to the quick and prompt response obtained when a nerve is 
normal. The usual method of testing is to apply first a slowly interrupted 
faradic current to the corresponding normal nerve, and then try the same 
current on the diseased nerve. If a nerve is completely diseased or 
severed, no reaction will be obtained to the faradic current. The galvanic 
current is then tried, and a minimum current applied to the diseased 



PLATE IX 




Inf. Hemorrhoidal 

ofPudic 

Superficial Perineal of\ 

Pudic and Inferior I 

Pudendal of small I 

Sciatic ^ 



'? \ 



The Distribution of Sensory Nerves in the Skin. (After Flower.) 

The areas of the skin supplied by the cutaneous nerves are shown in finely dotted 
outline. The circles on the trunk show areas occasionally anaesthetic in hysteria. The 
lines across the limbs at ankle, knee and thigh, wrist, elbow and shoulder show the upper 
limits of anassthesia in multiple neuritis of varying degrees of severity. 



DISEASES OF THE PERIPHERAL NERVES 215 

nerve first, when the response will be slow and sinuous. The same current 
applied to the healthy nerve will not cause any reaction, and to obtain a 
response it will be necessary to increase the current to such an extent 
that it will be painful. Reactions of degeneration are not obtained until 
about one or two weeks after the severance of the nerve, and tests for 
them should never be made as long as a nerve is inflamed or there is pain 
on pressure. The presence of these reactions makes the prognosis grave. 

Diseases of the Cranial Nerves. — Tic Douloureux. — Painful paroxysms 
of the fifth nerve are due to many causes, but in the majority of instances 
no ascertainable factor can be found. Repeated examinations of the 
Gasserian ganglia have demonstrated occasionally diseases of the nerve 
cells, but this is not constant and the real cause is not known. Rarely 
eyestrain, antrum disease, or dental irritation may cause pains in part 
of the distribution of the fifth nerve, but in a well-marked case of tic 
douloureux the cause is nearly always undefined. The disease may 
involve at first or be always limited to one branch of the fifth nerve, 
usually to the supra-orbital, when it is termed supra-orbital neuralgia. As 
a rule, it begins with an occasional numbness in one of the divisions, this 
becoming more frequent and severe, the onset of the disease lasting 
sometimes over a number of years, to be followed by pain which involves 
two and lastly all the branches. If the disease is limited to the supra- 
orbital nerve, pain will be marked over the forehead and brow and there 
will be pain in the eye and sometimes a sensation of a foreign body. 
Occasionally the pains will be so sharp as to cause closure of the eye with 
flow of tears. Inflammation limited to the middle or infra-orbital nerve, 
infra-orbital neuralgia, will cause numbness or pain in the upper jaw, 
palate, and upper teeth, and sometimes in the tongue. If the disease 
is limited to the inferior branch, the pain will be in the lower jaw, teeth, 
and tongue, it being aggravated by eating or talking. There will, 
besides, be pain on pressure over the nerves at their exits. If the disease 
involves all parts of the flfth nerve, the pain will come on spasmodically 
and cause the most excruciating pains over the whole side of the face, and 
contractions or spasms of the muscles. Accompanying this there may 
be flow of tears and pain on pressure over the exits of the nerve. At such 
times any irritation, no matter how slight, as talking or eating, will bring 
on a fresh attack, and there may also be hyperesthesia in the distribution 
of the trigeminus. 

The prognosis in a well-marked case is poor, inasmuch as operative 
procedure offers the only relief. In such case, whether the Gasserian 
ganglion be excised or the sensory root cut, relief of pain will be obtained 
and there will be anesthesia in the distribution of the fifth nerve. It is 
important to remember that while superficial sensation or the sensation 
for touch, pain, and temperature is lost, deep sensibility is retained, 
because of the fact that this sense is transmitted by the deep or muscular 
nerves, and not by the fifth nerve. It is because of this that very often 
a mistake is made in believing that the fifth nerve has not been cut, when, 
as a matter of fact, careful test will demonstrate that superficial sensa- 
tion is lost, and it is only deep pressure that is appreciated. 



216 



DISEASES OF THE NERVOUS SYSTEM 



Fig. 77 



Facial Tic and Spasm.— Until recently no differentiation was made 
between spasm and tic. By tic is meant a movement or movements 
which are more or less under the control of the will and result from some 
emotional or functional cause, duplicating or resembling voluntary 
movements. In whatever part tic takes place the muscular action is 
complete, as, for instance, in facial tic the contraction is in the whole facial 

distribution, its occurrence not 
interfering with the use of the 
same musculature for other pur- 
poses, as eating and talking. The 
movements are quick, intermit- 
tent, have a tendency to become 
chronic, and cease during sleep. 
On the contrary, by spasm is 
meant a movement which is not 
at all under the control of the 
will, and which cannot be volun- 
tarily duplicated. Contraction 
usually involves, at first, part, 
and later all, of a functionally 
acting group of muscles, and in- 
terferes with their use, as, for in- 
stance, in facial spasm, the con- 
traction may be limited first to a 
part and later involve all the facial 
distribution. The movement does 
not resemble a voluntary action 
and interferes with eating and 
talking. 

The causes of spasms and tics 
are not known, but it is prob- 
able that they are functional in 
origin. Rarely a spasm of the facial nerve may be caused by an intra- 
cranial tumor pressing upon the facial nerve just at its exit in the cere- 
bellopontile angle. 

Facial Palsy. — ^The facial, or seventh, nerve supplies the muscles of 
the face. Its nucleus is in the lower and posterior portions of the pons, 
and the nerve in its course outward surrounds the nucleus of the sixth 
nerve. Its exit is just between the pons and medulla. Because of 
this anatomical relation, any gross lesion involving the seventh nucleus 
will nearly always involve the sixth, and vice versa. The usual form 
of facial palsy is that known as peripheral, or Bell's, palsy. Lesions 
causing this may be either in the pons, at the exit of the nerve, at the base 
of the brain, in the Fallopian canal, or in its extracranial course 

Central facial palsy (Fig. 78) is that form of facial paralysis in which 
the lower part of the face only is paralyzed and is the result of a lesion in 
any portion of the central facial fibers between the facial centres in the 
cortex and its nucleus in the pons, as, for instance, in a capsular hemiplegia. 




Spasm of right facial nerve. 



DISEASES OF THE PERIPHERAL NERVES 



217 



The reason for the escape of the upper portion of the face in such paralysis 
is that wrinkhng the brow, in common with other bilateral functions, such 
as chewing, eating, and swallowing, has bilateral cortical innervation, 
and to cause paralysis of such functions there must be bilateral cerebral 
lesions. 

In a large majority of cases ordinary peripheral facial palsy is the 
result of a neuritis which may be of rheumatic origin or may follow a 
"cold." Rarely it is due to basal syphilis, tumors, fractures, etc. When 
resulting from a lesion in the pons, facial paralysis is generally accom- 




Right central facial palsy in hemiplegia, showing drooping of the right corner of the mouth. 
There is preservation of the movements of the brow. 

panied by other symptoms, such as palsy of the sixth nerve, paralysis of 
associated ocular movement, or hemiplegia upon the other side. Abscess 
of the middle ear is a common cause as well as mastoid operations. 
When the lesion is in the Fallopian canal we have in addition to the usual 
symptoms temporary disturbance of taste in the anterior two-thirds of 
the tongue because of involvement of the chorda tympani which runs 
along with the seventh nerve in the Fallopian canal (Fig. 79). 

The symptoms of peripheral paralysis of the facial nerve depend upon 
the degree of its involvement. When the paralysis is total there is 



218 



DISEASES OF THE NERVOUS SYSTEM 



inability to wrinkle the brow, to shut the eye, to elevate the corner of the 
mouth, to whistle, or to pronounce labials properly. Besides, there will 
be drooping of the lower lid and of the corner of the mouth, and the 
wrinkles on each side of the face will be smoothed out. Because of the 
drooping of the lower lid there will be widening of the palpebral fissure 
and excessive flow of tears because of the lack of proper conduction into 
the nasal cavity. Electrical reactions of degeneration will be found, 
their degree depending upon the extent of the neuritis. Sensory dis- 
turbances may be present at the onset, when the patient may complain 
of pain in the face, and there may also rarely be herpetic eruptions in 
the ear because of involvement of the geniculate ganglion. 



Fig. 79 




Left peripheral facial palsy, showing inability to wrinkle brow and show teeth on the 

paralyzed side. 

Most cases of peripheral facial paralysis recover, providing the cause 
is an ordinary neuritis such as results from ''colds" or rheumatism and 
prompt treatment is instituted. In those cases in which the nerve is 
cut, unless an anastomosis is performed, recovery cannot be expected. 
Sometimes years after the occurrence of such paralysis there may occur 
secondary contractures. 

Torticollis (Wry Neck) . — Inasmuch as the spinal accessory nerve sup- 
plies the sternomastoid and trapezius muscles, an irritation of it, such as 
results from pressure, will cause spasm in its distribution, or torticollis. 
In most instances, hoAvever, the cause is not known. It may come on 
suddenly as the result of fright, but usually the onset is gradual, the 



Xeck muscles 




i 



DISEASES OF THE CERVICAL NERVES 219 

spasm growing more and more severe, the particular kind depending 
upon the muscles involved. If the sternomastoid alone is involved, the 
head is turned to the opposite side, the chin pointing a little upward ; if the 
trapezius, the head is retracted toward the shoulder on the same side, the 
chin pointing upward; if both the sternomastoid and trapezius, the head 
is turned to the opposite side, backward, and the chin higher than when 
either are alone diseased. Very often, in association with the sterno- 
mastoid and trapezius muscles, the rotators of the neck, muscles of the 
shoulder, the rectus capitis, and splenius muscles of one or both sides 
partake in the spasm, and the movements are complicated. When the 
rotators alone are involved, the head is turned toward the same side, 
the chin being on a straight line; when the splenius, the head is retracted, 
the chin upward, differing from the action of the trapezius in the fact that 
in the latter the head is retracted toward the shoulder. \Mien both 
sternomastoids are involved the head will be drawn forward, and if the 
movements are clonic there will result so-called nodding, or salutatory, 
spasms, which are especially common in children. The spasms may be 
tonic, w^hen it is difficult to return the head to its original position, 
or clonic, the movements being intermittent. Ordinary stiff neck, or 
rheumatic torticollis, hardly enters into the discussion. The course of 
the disease, as a rule, is long and the prognosis not very good. It is best 
in those cases in w^hich treatment is instituted early and in which absolute 
control of the patient can be obtained. 



DISEASES OF THE CERVICAL NERVES. 

Cervical, or Occipital, Neuralgia. — The first four cervical nerves are some- 
times diseased alone or in association with the cervical nerves which 
enter into the brachial plexus. ^Mien they alone are diseased and the 
posterior primary divisions are involved, there will be pain along the distri- 
bution of the great, third, and small occipital and the auricularis magnus 
nerves, and the pain will be very marked in the back of the neck and scalp 
up as far as the vertex. Besides, there will be pain on pressure over this 
part and especially over the exits of these nerves. The pains may be 
constant or may come on spasmodically and be so intense as to prevent 
the patient from moving the head and neck. Occasionally there may 
be dropping out of the hair from the affected scalp. 

Brachial Neuritis. — The brachial plexus is composed of the fifth, sixth, 
seventh, and eighth cervical and the first thoracic roots, and supplies 
motion and sensation to the upper limb. A neuritis may involve all of 
the branches of the plexus or be limited to its parts, especially the fifth 
and sixth cervical or the seventh and eighth cervical and the first thoracic 
roots or their continuations. There may be in association with this an 
involvement of the first four cervical nerves, when it is called a cervico- 
brachial neuritis. If the whole brachial plexus is affected, the symptoms 
will depend largely upon the severity of the disease. There will be pain 
in the shoulder and the axilla, this radiating along the whole arm, and 



220 DISEASES OF THE NERVOUS SYSTEM 

pain on pressure over the nerve trunks. In fact, there will be pain over 
the whole upper limb, and any movement or pressure will aggravate it. 
In association with this neuritis there is always paralysis either of a 
whole or of a part of the upper limb. 

If the upper cords of the brachial plexus, i. e., the fifth and sixth 
cervical roots, are diseased, the pain will be limited to the neck, shoulder 
and to the arm as far as the elbow, there being pain on pressure over these 
parts; if to the lower part of the brachial plexus, i. e., the seventh and 
eighth cervical and first thoracic roots, or their continuations, the pain 
will be limited to the forearm and muscles of the hand. In association 
with both these types of neuritis there will be more or less paralysis in 
the same parts. 

Brachial Neuralgia. — The difference between brachial neuritis and 
neuralgia is that in the latter the pains are spasmodic in character, there 
is pain on pressure over the nerve trunks and the arm only at the time 
of the pains, and there will not be an accompanying paralysis. 

Brachial Palsy. — Paralysis of the brachial plexus may be total or 
partial, unilateral or bilateral. If total, the arm hangs limp by the side, 
no movements being possible; the muscles are atrophic, electrical reac- 
tions of degeneration are obtained, and atrophic phenomena are present. 
Partial brachial paralysis may be either of the upper plexus type, the 
so-called Duchenne-Erb form, in which the fifth and sixth cervical roots 
or the fibers in the plexus coming from these roots are involved, or the 
Klumpke, or lower plexus, type, in which the eighth cervical and the first 
dorsal roots are diseased. 

In the upper plexus form the deltoid, triceps, brachialis anticus, the 
supinator longus and brevis, and the infraspinatus muscles are affected. 
It is impossible to adduct the arm and the forearm is extended and pro- 
nated. Sensation, as a rule, is not disturbed. The muscles are atrophic, 
and there may be reactions of degeneration. In the Klumpke paralysis 
the small muscles of the hand and a number of muscles of the forearm, 
especially the flexors, are paralyzed. Sensory disturbances are common 
in the hand and forearm, especially in the ulnar distribution. 

These different types of brachial plexus paralysis are mostly trau- 
matic in origin, and may be due to blows, gunshot or stab wounds, 
fracture of the head of the humerus, dislocation of the shoulder, and 
tumors. The so-called obstetrical and most narcosis paralyses are 
included in the upper arm type. The disease may also occur idio- 
pathically, the cause probably being toxic. 

Involvement of the Sympathetic System. Ocular Symptoms. — Oculo- 
pupillary symptoms, consisting in a narrowing of the pupil and of the 
palpebral fissure, can occur only if the first dorsal roots are involved 
either in the intervertebral foramen or before their separation from the 
rami communicantes. Therefore, in the lower arm type of paralysis, 
in which the eighth cervical and the first dorsal roots are diseased, we 
always have oculopupillary symptoms. It is possible, however, to have 
this type of paralysis without sympathetic involvement, if the fibers 
in the brachial plexus, coming from these roots and not the roots them- 



DISEASES OF THE CERVICAL NERVES 221 

selves, are diseased. It is difficult, however, to make such a clinical 
differential diagnosis because the symptoms are identical, but we can 
always assume that if the oculopupillary symptoms are present the first 
dorsal root is diseased. 

In the Duchenne-Erb type of paralysis, due to a birth palsy, or the 
paralysis occurring in the course of etherization, the traction upon the 
arms may cause an abnormal stretching and tearing of the rami communi- 
cantes of the first dorsal root, thus causing sympathetic paralysis without 
the first dorsal root itself being diseased. 

If all of the roots of the brachial plexus are diseased we may have 
oculopupillary symptoms. As a result of gunshot or stab wounds we 
may have forms of paralysis which do not conform to any of the known 
types with sympathetic symptoms. In these cases either the first dorsal 
roots are involved or the oculopupillary fibers in the cervical sympathetic 
are injured. 

Paralysis of the Circumflex Nerve. — ^This results from dislocations and 
injuries to the shoulder, and produces paralysis of the deltoid muscle 
with accompanying atrophy and inability to adduct the arm. If there 
is a neuritis, there will be pain on pressure over the shoulder and dis- 
turbance of sensation. 

Paralysis of the Long or Posterior Thoracic. — This results sometimes 
from lifting heavy weights or injuries and dislocations to the shoulder, 
and causes paralysis of the serratus magnus muscle. The lower edge 
of the scapula, to which the serratus magnus is attached, will be moved 
nearer the spine and become very prominent and there will be inability to 
lift up the arm more than to the horizontal plane. There may be pain 
on pressure over the scapula and neck and disturbance of sensation. 

Musculospiral Palsy. — ^This nerve is very frequently injured or diseased 
because of its exposed position around the humerus. It generally is 
found affected after a debauch, the patient, while intoxicated, lying on 
his arm, thus causing pressure and paralysis. It is sometimes called 
"Saturday night" palsy. There is wrist drop with inability to extend 
the fingers, and pain on pressure over the nerve, with disturbance of 
sensation over the extensor surface of the arm. 

Median Nerve Palsy. — Median nerve palsy is generally due to injuries. 
This nerve supplies all the flexors of the fingers, the flexor carpi radialis 
and the pronator radii teres, and its paralysis causes inability to flex the 
fingers or abduct or adduct the thumb or to pronate the forearm. There 
may be pain on pressure over the nerve and some sensory disturbances 
over the palm of the hand, to be followed later by atrophy in the involved 
muscles. 

Ulnar Palsy. — ^This is usually produced by direct injury to the nerve. 
It supplies the fiexor carpi ulnaris, the ulnar half of the flexor profundus 
digitorum, the muscles of the hypothenar eminence, the interossei, 
the inner three Lumbricales, the adductor pollicis, and the flexor brevis 
pollicis. In ulnar paralysis there is disturbance of flexion of the hand 
and of the last three fingers, inability to flex the proximal and extend 
the terminal phalanges of the fingers. This is especially marked in 



222 DISEASES OF THE NERVOUS SYSTEM 

the last two fingers, and there is also some weakness in adduction of 
the thumb, this disturbance causing the so-called "claw hand/' it being 
more marked later when there is atrophy in the involved muscles. Sen- 
sory disturbances are not frequent, and, when present, are limited to the 
flexor and extensor surfaces of the last two or three fingers. 



DISEASES OF THE THORACIC NERVES. 

Intercostal Neuralgia. — ^This may be due to a variety of causes, the symp- 
toms, as a rule, being unilateral. There is spasmodic pain around the 
chest of a sharp, shooting character, tenderness over the nerve and over 
the foramina, and sometimes an herpetic eruption. 



DISEASES OF THE LUMBAR AND SACRAL NERVES. 

Only very rarely are the plexuses of these nerves diseased either inde- 
pendently or together. The most frequent nerves to be affected are the 
sciatic and the external popliteal and its divisions. 

Sciatica. — This may be due to a variety of causes. If there is neuritis, 
it is generally rheumatic in origin and there is constant pain on pressure 
over the whole extent of the nerve along the back of the thigh and leg 
as far as the ankle, pain on pressure over the nerve trunk, also pain when 
the thigh is extended on the abdomen, causing stretching of the nerve. 
Because of the pain the patient in walking will bend to the opposite side, 
and sometimes a scoliosis will result in an effort to save the diseased 
leg. There will also be loss of the Achilles jerk. Occasionally there is 
paralysis of the muscles below the knee. 

Paralysis of the External Popliteal Nerve. — ^This is mostly due to direct 
injury. The nerve has two divisions, the peroneal and the anterior tibial. 
If both are involved, there will be foot drop with inability to dorsally flex 
the toes or foot or to deviate the foot outward. If the peroneal nerve is 
involved alone, there will be foot drop, with inability to deviate the foot 
outward, but slight dorsal flexion of the large toe will be possible. If 
the anterior tibial nerve is diseased, it will be impossible to dorsally flex 
the large or any of the toes, but deviation of the foot outward will be 
possible. 

Tumors of the Nerves. — ^These are of rare occurrence and are 
generally fibromata, but sarcoma, angioma, or any of the other usual 
forms may occur. The tumor may develop within or upon a nerve 
sheath. The amputation fibroneuroma is the best example of a true 
nervous tumor; it is possible that pure neuromata do not exist. 

Fibroma may sometimes grow upon one nerve, or may rarely involve 
all the nerves of the body, even the cranial nerves, constituting Reckling- 
hausen's disease. 



Mvscles of back 




I 



CHAPTER XII. 

THE HEAD, FACE, AND NECK. 
THE HEAD. 

The diagnosis of surgical affections of the skull and its teguments 
and accessory cavities is considered under this heading. The surgical 
affections of the brain and its envelopes, except those which are 
traumatic and acutely infective, are discussed under affections of the 
nervous system. 

The diagnosis of traumatic lesions of the cranium and its teguments 
is important mainly only so far as it concerns the presence or absence of 
injury to the brain or its vessels and nerves. 

Contusion. — Head injuries of this nature may be superficial, in which 
case the scalp and periosteum alone are involved; or deep, producing 
fractures of the bone and lesions of the brain and its meninges. The 
brain may exhibit lesions even though the skull has not been fractured, 
the resiliency of the bony case being sufficient to enable it to withstand 
a trauma which, by suddenly driving in a part of its walls, bruises or 
lacerates the brain substance. 

Contusions of the scalp are characterized by rapid swelling incident 
to the free bleeding which is dependent upon the vascularity of the part 
and the looseness of the tissue texture. This bleeding commonly takes 
place in the subcutaneous tissue. It then forms a hard, discolored, 
circumscribed tumor, movable with the scalp. 

The vessels torn may lie beneath the aponeurosis of the occipito- 
frontalis muscle or beneath the periosteum. In the former case the 
swelling is less sharply defined, and in both instances readily pits in the 
centre, and does not move with the aponeurosis. It may present around 
a soft, depressible centre, caused by the impact of a blow, a ring of 
almost bony hardness, due to coagulated fibrin. To the examining 
finger the sensation is so like that characteristic of a depressed fracture 
of the skull that the scalp has often been incised and raised before a 
correct diagnosis could be made. It is usually possible to form a non- 
operative differential diagnosis by making firm rubbing pressure con- 
tinued for several minutes over a part of what is apparently the bony 
wall of the depressed fracture. As the edema and coagulated blood are 
gradually pressed aside, the smooth, unbroken surface of the skull can 
be felt. 

Contusions of the scalp in the frontal region are commonly followed by 
swelling and ecchymosis of both eyelids from gravitation of the blood. 
When a comparatively large vessel has been torn a pulsating tumor may 
be formed, or, when free bleeding occurs beneath the aponeurosis, there 



224 THE HEAD, FACE, AND NECK 

may be a fluid accumulation which can be pressed from the occipital to 
the frontal and temporal regions. 

From infection of these effusions abscesses or cellulitis may develop. 
Usually they undergo prompt resolution; exceptionally they persist as 
fluctuating tumors, or when they are subperiosteal, they may be followed 
by bony outgrowth sequent to bone contusion ; headache, neuralgia, and 
epilepsy are recorded. 

Depending upon the position and extent of the lesions due to contusion 
of the brain, this condition is manifested by the symptoms of concussion, 
of focal irritation, or of compression. 

Concussion. — Concussion is, doubtless, a bruising, even though the 
force be of such slight degree as to produce no demonstrable lesions ; , in 
its severer forms the gross lesions may be at the point of impact, opposite 
to this, or in any part of the brain, but particularly at the tips of the 
temporal lobes and the base of the frontal lobe. 

Concussion may be slight, moderate, or severe. Slight concussion 
is characterized by a momentary confusion, or insensibility, attended 
with muscular relaxation, pallor, and a feeble pulse. Nausea and 
vomiting often accompany return to consciousness. The symptoms 
are similar to those of fainting from emotional causes. 

Moderate concussion is characterized by complete loss of consciousness, 
pallor, shallow respiration, feeble, often irregular pulse, muscular 
relaxation. The face is calm, the eyelids closed, the pupils dilated and 
even. There may be an evacuation of feces and urine. In a few 
minutes, or within the hour, consciousness is regained, there is some 
nausea and vomiting, and, after a varying period of muscular weakness 
and mental irritability and confusion, there is left only a dull headache. 
The mental impressions immediately preceding the concussion are often 
abolished. 

Severe concussion is characterized by slow and incomplete reaction 
from the symptoms of moderate concussion. It may terminate fatally. 
The primal insensibility is followed by a condition of stupor. The first 
incontinence of urine and feces is followed by retention, with overflow 
and constipation. The patient often lies on his side with flexed limbs 
in a condition of hebetude from which he can be momentarily aroused ; 
at times a condition of cerebral irritability develops, characterized by 
peevishness, restlessness, and active delirium. Gradually consciousness 
is regained, but clear mind and efficient memory come slowly. The 
temperature is often subnormal. 

Focal Irritation. — The intracranial lesions of contusion of the skufl, 
if definitely localized, are most likely to appear in the cortical gray 
matter and to be superficial. When such lesions are not severe enough 
to destroy function and produce paralysis, they cause focal irritation. 
The presence of localized moderate bruising can usually be determined 
only when such foci are placed in or near the motor centres. Thus 
localized or unilateral twitchings, convulsions, or paralysis would sug- 
gest contusion and bleeding the seat of which would be determined by 
an application of the general principles of cerebral localization. The 



THE HEAD 



225 



stupor or prolonged irritability following concussion is, in the absence 
of the general symptoms of increased cerebral pressure, evidence of 
a focal irritation of the psychical centres. 

Compression.— The symptoms of acute cerebral compression are 
caused by a rapid encroachment upon the space which should be occupied 
bv the brain. When compression is incident to contusion and follows 
such an injury immediately or within a few hours, the cause of the 
increased intracranial pressure, if not dependent upon depressed bone, 
must necessarily be hemorrhage. 

Acute traumatic compression of the brain in its full development is 
characterized by coma, tortuous and dilated retinal veins, slow, snoring 
respirations, hard, slow, full 

pulse (compensatory increase ^^^- ^^ 

in blood pressure), paralysis, 
subnormal temperature in the 
shock period, followed usually 
by slight fever. As death ap- 
proaches the pulse becomes 
weak and hurried, the respi- 
rations are rhythmically ir- 
regular (Cheyne-Stokes), the 
pupils dilate, and the tem- 
perature rapidly rises. 

The hemorrhage may be 
extradural, subdural, or cere- 
bral. Extradural hemor- 
rhage, between the dura and 
the bone, is commonly due 
to laceration of the anterior 
branch of the middle menin- 
geal artery. This injury may 
occur without fissure or frac- 
ture of the bone, and excep- 
tionally from the vessel on 
the side opposite to that 
which is directly injured. 

The specific symptoms of 
this lesion are usually masked by those of severe concussion, or of 
compression from subdural or intracerebral bleeding. 

When this is not the case, a person who has been injured by a blow 
which caused a slight transitory condition of concussion seems entirely 
recovered from the effect of the violence, except for the slight dulness 
and muscular weakness which are the invariable sequelse of a cerebral 
jar. After a brief interval^ usually a few hours, there develops a severe 
headache which becomes steadily worse, is followed by nausea and 
vomiting, aphasia if the lesion be on the left side, weakness in the hand 
and arm then in the leg of the side opposite the lesion, stupor, later 
twitching and convulsive movement which involve the face, hemiplegia, 
X5 




Compression following hemorrhage from the middle 
meningeal artery. (Helferich.) 



226 THE HEAD, FACE, AND NECK 

increased arterial tension and slow pulse, coma, Cheyne-Stokes breathing, 
and death. The pupils are at first contracted, then dilated, particularly 
the one on the affected side. To this rule there are exceptions. 

The severe headache is due to the stripping and irritation of the dura 
by the accumulating clot; the aphasia, unilateral paresis, twitching, and 
paralysis to the pressure focused over the motor centres; the coma 
and symptoms of cerebral compression to the general increase of cerebral 
pressure. Paralysis of the cranial nerves of the affected side may be 
caused by the extravasated blood reaching the base of the cranium and 
pressing upon the nerve trunks. 

The diagnostic features of extradural hemorrhage following trauma 
are, then: (1) The presence of a contusion in the temporoparietal region; 
(2) an interval of freedom from symptoms (hours) followed by violent 
headache; (3) signs of pressure over the motor centres; (4) symptoms 
of cerebral compression. 

There is no non-operative way of determining the origin of the bleeding. 
If not from the anterior branch of the middle meningeal artery it is 
usually from the posterior branch. Neither injury to the sinus nor 
the other dural vessels, which may be torn by contusion, is likely to 
cause a hemorrhage which will dissect up the dura and exert an irri- 
tating then a paralyzing pressure upon the motor centres before it 
causes symptoms of general cerebral compression. 

The diagnosis of subdural hemorrhage can often be made by lumbar 
puncture, which withdraws a blood-stained fluid. When pressure 
symptoms are so great as to threaten life, it should be made by a 
decompression operation in one or both temporal regions unless the 
symptoms of focal irritation point to another region. 

When, after an injury to the head, it is necessary to distinguish between 
concussion and compression, it should be borne in mind that concussion 
resembles syncope, with the insensibility which shortly becomes only 
partial, relaxation, feeble pulse, and shallow respirations of that con- 
dition. The diagnosis of pure concussion without brain lesion can be 
framed only when a patient promptly and completely recovers- from 
such injury without headache, confusion, irritability or any other sign or 
symptom suggesting a departure from his usual mental health. Exten- 
sive lesions may be accompanied at first by the slightest degree of con- 
cussion. Compression in addition to the insensibility is attended, at 
least in its earlier stages, with a full, hard pulse, a slow, snoring respira- 
tion, and often hemiplegia. 

Following cerebral hemorrhage, whether this be spontaneous or due 
to trauma, in the course of from one to three days there is an edema 
which, if diffuse and sufficiently pronounced to interfere with cerebral 
circulation, accentuates the symptoms of compression should they have 
been present; or, in case of localized trauma attended with symptoms 
of slight concussion, causes mental confusion, delirium, stupor, or the 
slowed pulse and congested tortuous retinal veins of pronounced 
compression. 

Aside from the complications due to infection, L e., meningitis. 



THE HEAD 227 

encephalitis, and abscess, there may follow contusion of the brain either 
immediately or after a long interval ; headache, which may be so severe 
and persistent as to be cripphng; loss of the senses of smell and taste; 
neurasthenia with its typical inconstancy and multiplicity of symptoms; 
loss of memory and inability for mental application; impotence, palsies, 
traumatic epilepsy, insanity. 

Birth Injuries of the Head. — The ccifut succedaneum, a rounded, 
pitting, non-fluctuating, edematous swelling of the soft parts, usually 
in the occipitoparietal region, has attained its maximum at birth and 
shortly disappears. 

Cephalhematoma, due to subpericranial bleeding and incident to 
difficult labor, is characterized by the development after birth and often 
progressive increase in size for several days, of a fluctuating cranial area, 
sometimes bilateral, irregular in peripheral contour, and corresponding 
with that of the ossified portion of the underlying bone, usually the 
parietal. Absorption may be slow (weeks) or the tumor may persist. 

Indentation and fracture of the cranial hones, usually accompanied 
by obvious deformity, is of importance as indicating probable subdural 
hemorrhage and brain lesion. 

Intracranial hemorrhage, usually subdural, is characterized by promi- 
nent fontanelles, dilatation of the surface veins and those of the retina, 
slow or irregular pulse, irregular, at times Cheyne-Stokes, respiration, 
inability to suckle, twitchings or convulsions. 

The absolute diagnosis must be made by exploration. 

Fracture of the Skull. — Fractures of the skull are conveniently 
classed as of the vault and of the base. They may be partial, involving 
either the external or internal table, or complete, involving the entire 
thickness of the bone. They may be simple or compound, fissured 
without displacement, or depressed. Depressed fractures are formed 
at the seat of impact; fissured fractures commonly extend from this, 
but may through their entire course be remote from it. 

Fractures of the Vault. — When these injuries occur as the result of con- 
tusions, they may be positively diagnosticated provided there is depression, 
crepitus, and a cracked-pot percussion note. This depression must 
not be mistaken for that sometimes noted in simple contusion of the 
scalp. The yielding of the broken bone when it is not impacted, the 
sharp, irregular edge of, the depression, and the impossibility of affecting 
the bony margins of the depression by steady, continuous massage and 
pressure, are signs peculiar to depressed fracture. Skull deformity 
incident to previous lesions should not mislead. A fissured fracture of 
the vault without displacement can, in the absence of a wound, be 
detected only by exploratory incision or the a;-rays. It may be suggested 
by persistent bone tenderness. 

When the fracture is compound the area of depression can be both 
seen and felt. A moderate depression may involve the outer table 
alone. Over the frontal sinuses a pronounced depression may be 
present without involving the inner walls of these cavities. This can 
be determined only by the use of the trephine. 



228 



THE HEAD, FACE, AND NECK 



Fissured fractures are manifested by a sharply marked blood-stained 
line running through the bone. Often there is a distinct edge from 
slight inward displacement of one fragment. Fracture of the inner 
table without lesion to the outer may possibly be detected by the x-rays ; 
such fractures are much rarer than fractures of the outer table without 
injury to the inner. 

Fractures of the Base. — These are caused by force applied to the 
vault, by force applied through the spinal column, as from the jamming 
down of the skull incident to a heavy fall upon the buttocks, or by the 
direct penetration of a vulnerating body, as a bullet or foil. 



Fig. 81 



Fig. 82 





Bursting fracture of the base. 
(Von Bergmann.) 



Circular fracture of the base. 
(Von Bergmann.) 



The diagnostic features of fracture of the base of the skull are: Per- 
sistent bleeding followed by a flow of cerebrospinal fluid from the nose, 
mouth, and ears, paralysis of one or more of the cranial nerves, and 
usually the symptoms of cerebral concussion or compression. All three 
fossae are often fractured. 

Fractures of the anterior fossa are commonly due to force applied to 
the front part of the cranial vault. The first characteristic symptom 
is free persistent bleeding from the nose; the blood may trickle back 
into the pharynx, and may be followed after some hours by a slow, 
steady flow of cerebrospinal fluid. 

This escape of cerebrospinal fluid from the nose is diagnostic of 
fracture of the ethmoid or the body of the sphenoid. In the former case 
there is exceptionally loss of the sense of smell; in the latter there may 
be partial or complete paralysis of the optic nerve, causing blindness, or 
of the oculomotor nerves, causing dilatation of the pupil and divergent 
strabismus. 

The bleeding must be distinguished from that due to fracture of the 



PLATE XII 







Fractures of the Base of the Skull. Illustrative lines of fissure or fracture 
are printed in red. (Park.) 



THE HEAD 



229 



vomer or lesion of the mucous membrane of the nose. In fracture of 
the nasal bone the force is commonly applied directly to the bridge of the 
nose; in fracture of the base of the skull the force is applied to the 



Fig. 83 



Fig. 84 





Longitudinal fracture of the base, 
(yon Bergmann.) 



Fracture of base, from fall from scaffolding. 
Hemorrhage from right ear and nose. Death 
from meningitis. (Von Bergmann.) 



anterior temporal or the frontal region. Fig. 85 

Fracture of the nasal bones can be de- 
tected by direct examination, and some- 
times the mucous membrane lesions 
and the source of bleeding can be 
seen with the rhinoscope. The bleed- 
ing of fracture of the nasal bones is 
commonly free at first, but is less likely 
to be persistent and is not followed 
by a steady, persistent oozing. 

^^^len the fracture involyes the 
roof of the orbit, there may develop 
shortly a projection of the eyeball, 
and after one or two days sub- 
conjunctival ecchymosis followed by 
palpebral discoloration. The blood 
lies beneath the ocular conjunctiva and 
not in its substance, is dark in color, 
and reaches the lids after it has ap- 
peared beneath the ocular conjunctiva. 
This symptom is not pathognomonic. 

Fractures of the middle fossa, commonly due to violence applied to 
the parietal or the temporal region, is characterized by free, persistent 




lurstmg 



fracture. Patient slipped, 
striking head on a stone. Direction of 
force indicated by arrow. (Von Berg- 
mann.) 



230 THE HEAD, FACE, AND NECK 

bleeding from the ear, followed by an oozing of cerebrospinal fluid. 
There is sometimes facial palsy and deafness. The line of fracture is 
likely to run in the long axis of the petrous portion of the temporal bone. 

When the violence is applied to the occipital region, the fracture is 
likely to be transverse; and in this case all these symptoms are more 
marked, especially the flow of cerebrospinal fluid; deafness and facial 
palsy are more commonly developed. 

Fractures involving the apex of the petrous portion of the temporal 
bone may cause paralysis of the sixth (abducens) nerve, with convergent 
squint of the affected side. This, a common paralysis, is observed 
after comparatively slight injuries and may be transitory. Facial 
palsy is peripheral in type. It may be observed immediately after 
the injury, in which case it is due to contusion or rupture of the 
nerve and is often irreparable; it more commonly develops in a few 
days, and is then due to pressure incident to the congestion of bone 
repair, and is self-limited. 

Free bleeding from the ear is not necessarily a sign of basilar fracture. 
The blood may come from a fracture involving the external auditory 
meatus, such injury being usually inflicted by a blow on the point of the 
chin, which drives the condyles upward and backward; or the blood 
may come from a ruptured tympanic membrane. In either case exami- 
nation with an otoscope will show the source of the bleeding. In the 
latter case the hemorrhage is likely to be slight and soon stops; more- 
over, it is not followed by the escape of cerebrospinal fluid. 

The discharge of the fluid from the ear may be slight, lasting but a 
few hours, or may be profuse, lasting for a week or more. It is the most 
constant pathognomonic sign of fracture of the middle fossa. 

Fractures of the posterior fossa of the skull, unless compound, present 
no diagnostic features. The violence causing such injury is applied 
to the back of the head, as from a fall on the occiput or the base of the 
skull, or from the jar incident to a fall on the feet or the buttocks. 
When there has been no direct trauma to this region, ecchymosis above 
the mastoid and in the back of the neck, developing two or three days 
after traumatism, would be suggestive of fracture. Effusion of blood 
and cerebrospinal fluid behind the posterior wall of the pharynx is 
positively diagnostic when it is practicable to detect it. 

Compound fracture of the vault, as well as marked flssured fracture 
of the base, may be attended with a slight transitory concussion; while 
fatal contusion of the brain may be caused by a trauma which does not 
fracture the bones. In itself, fracture of the skull is an injury of minor 
importance. The need of determining its presence is dependent upon 
the immediate and remote brain lesions it may cause either by direct 
pressure or by opening the route to infection. 

Traumatic Encephalohydrocele. — In infancy, the softness of the bones 
allows of great depression without fracture, and this same quality 
prevents the extension of fissures from the vault to the base. The 
elasticity of the bones of the vault allows of the infliction of a severe 
contusion or fracture without any of the deforming incident to the latter. 



THE HEAD 231 

As a result of such injury or of disjunction of the sutures, trau- 
matic encephalocele or encephalohydrocele may develop. The en- 
cephalocele develops immediately. The encephalohydrocele weeks or 
months after the injury. 

The characteristic features of encephalohydrocele are a history of 
injury to the head of an infant and the formation of a fluctuating 
pulsatile tumor which becomes tense on expiration and on straining, 
which is more or less reducible, and which contains cerebrospinal 
fluid. 

Wounds of the Cranium. — Wounds of the cranium may be non- 
penetrating or penetrating. The diagnosis of non-penetrating wounds 
of the scalp is obvious. Contused wounds, such as those inflicted by a 
club, often present the appearance of a clean incision with the exception 
of a slight line of abrasion along the skin edge. Involvement of the bone 
is determined by inspection and palpation when the wound is an open 
one; by probing and enlarging the opening when the scalp is simply 
punctured. 

When such wounds refuse to heal, a discharging sinus persisting at or 
near the seat of injury, a careful search will nearly always show the 
presence of dead bone or a foreign body, as a splinter of wood. 

Penetrating Wounds of the Cranium. — The diagnosis of penetration 
may be difficult to establish, as in the case of a blow on the head with 
the small blade of a penknife, or the thrust of a stick into the orbit or 
the nose, or through the roof of the mouth. Such wounds are excep- 
tionally followed by a hemorrhage so free as to produce compression, 
either immediately or within a few hours. Commonly the first sign 
of penetration is the development of a meningitis or encephalitis (hours, 
days). Exceptionally there is an interval of weeks or months in which 
there are no symptoms, followed by the symptoms of brain abscess. 

Penetration in case of punctured wounds of the vault is best established 
by an exploratory operation, the scalp being raised, and, should there 
still be a doubt, a button of bone being removed. Where punctures of 
the roof of the orbit are suspected but cannot be verified by the probe 
a two-inch incision just beneath the superciliary ridge carried down to 
the bone and deepened by blunt dissection along the surface of the 
orbital plate will enable the surgeon to determine the presence of a 
puncture in it. Punctures through the nose or palate, if not followed 
by immediate cerebral symptoms, and, if their presence cannot be 
determined by probing, can be suspected only from the nature of the 
injury and the character of the vulnerating body. 

Traumatic prolapse of the brain is characterized by the appearance 
of brain matter through a fracture, usually of the vault of the skull. 
There may be escape of brain substance from the orbit or the ear or the 
nose. The prolapse may occur immediately or may be secondary to the 
increase of intracranial pressure incident to trauma or infection. It 
forms a soft, gray, pulsatile, partly reducible tumor. The diagnosis is 
based on the macroscopic appearance and on microscopic examination. 

Fungus cerebri is a mushroom-like growth made up of granulation 



232 THE HEAD, FACE, AND NECK 

tissue and broken-down blood clot. It is caused by infection and 
grows from beneath the dura. It forms a sloughing, vascular, pulsating, 
suppurating tumor which exhibits a marked tendency to overlap the 
opening through which it projects. Unless complicated by diffuse 
encephalomeningitis it causes no symptoms. Fungus cerebri develops 
more slowly than cerebral prolapse, is always caused by infection, and 
a microscopic section of excised portions shows the traces of brain 
substance. 

Gunshot wounds of the cranium are usually penetrating. The bullet 
commonly pursues a straight course; exceptionally it is deflected, pro- 
ducing a contusion of the bone, a fracture of the outer or inner table, or a 
complete fracture, the missile then passing between the bone and the 
scalp. The fact of penetration is determined by the probe. When 
this fact is established, the course and length of the wound track and 
the position of the ball remain to be determined. The majority of gun- 
shot wounds of the brain are inflicted by revolvers of 22, 32, 38, or 44 
caliber. In the cheaper weapons of these calibers the penetration is 
poor and varies greatly. The best weapon at close range may be counted 
to carry a 22 ball through the skull and into the brain ; a 32 ball through 
the brain to the opposite side of the skull, producing a comminuted 
fracture at this point; a 38 ball through and through, or through the 
bone and to the skin of the opposite side; a 44 ball through and through, 
passing out at a wound of exit. 

The bullet of the air rifle and the 22 Flobert can penetrate the brain 
through the orbit, or through the thinnest part of the temporal bone. 

The ball, after it has penetrated the skull, usually pursues a straight 
course. If it reaches the opposite side of the skull, it may pass through, 
may remain at the point of impact, or may rebound or glance. Its 
position is best determined by the x-rays. 

Meningitis is not infrequently a complication of compound fractures, 
including those of the base. 

Acute osteomyelitis after fracture of the posterior fossa is a rare 
complication. In the absence of an overshadowing meningitis it is 
characterized by the constitutional signs of sepsis, rigidity of the neck 
muscles, severe pain radiating down the neck, and edematous swelling of 
the posterior pharyngeal wall. 

Inflammatory Affections of the Scalp and Cranium. — ^The usual 
acute superficial infections include furuncle, carbuncle, abscess, and 
cellulitis. The diagnosis is based upon the obvious symptoms. Acute 
osteomyelitis is characterized by the violence of constitutional symptoms 
which precede obvious local manifestations aside from deep pain, tender- 
ness, and edema. 

The chronic infections are exceptionally tuberculous, usually syphilitic, 
or incident to infection of a sebaceous cyst. 

Of the superficial skin lesions of the chronic type, those commonly 
encountered on the scalp are seborrhea, in both its dry and oily forms 
(p. 91), eczema, and, in children, tinea and the lesions incident to 
pediculi. 



THE HEAD 233 

Furuncles disseminated over the scalp, if painless, chronic, and 
without peripheral redness and edema, are usually manifestations of 
secondary syphilis. 

Abscess of the S(?alp, usually due to infection of an undrained wound 
or of a hematoma, is heralded by an increase of swelling and edema, 
together with pain,, heat, and redness. After the first twenty-four hours 
a wound or contusion should steadily grow less painful and tender, and 
after forty-eight hours there should be a rapid diminution in the swelling. 
When this is not the case, infection should be suspected. The absolute 
diagnosis is established by opening a wound which has closed, or by 
incision. Pus in appreciable quantities is rarely present before the 
third day. 

Superficial cellulitis, or cutaneous erysipelas of the scalp, is charac- 
terized by a hot, red, tender, edematous area of skin with raised, 
irregular, well-marked borders. Its tendency is toward rapid exten- 
sion and it often involves the entire scalp. It may be secondary 
to the superficial infection. It commonly follows infected wounds 
involving the aponeurosis and the periosteum. If it reaches the ear and 
forehead, small vesicles may develop in the skin, and the upper eyelids 
become greatly swollen. The lymphatic ganglia in the neck are 
promptly enlarged. It is inaugurated by chill, fever, and vomiting, 
and is often accompanied by intense headache, sometimes by de- 
lirium. 

It is characterized by the rapidly spreading area of heat, tenderness, 
and edematous swelling and the constitutional symptoms of pronounced 
sepsis, often inaugurated by a chill. It has for its chief danger com- 
plicating osteomyelitis or suppurative meningitis. 

Tuberculosis. — ^Tuberculous ulceration of the scalp (rare), secondary 
to tuberculous osteomyelitis of the cranial bones, is a disease of early 
childhood, and is nearly always associated with other more obvious 
tuberculous lesions. Local pain and tenderness are followed by the 
development of a flaccid, fluctuating tumor, without peripheral indura- 
tion, which slowly opens at one point and discharges tuberculous pus. 
Through the resulting sinus may be felt a sequestrum usually formed 
at the expense of the entire thickness of the bone, leaving a round 
perforation without surrounding hyperostosis, through which the pulsa- 
tions of the brain may be communicated to the abscess before it is 
opened. The frontal, parietal, and temporal bones are the usual seats 
of this rare affection. 

The ethmoid, body of the sphenoid, and petrous portion of the tem- 
poral bone are secondarily affected by tuberculous processes extending 
from the nasal cavity or the middle ear. 

The symptoms, if any, would be those of tuberculous meningitis, 
or of pressure from abscess, or of bleeding incident to erosion. 

Syphilis. — ^The papular and pustular lesions of secondary syphilis 
are common on the scalp, usually as a part of a general eruption. 

Nodules on the frontal and parietal bones, causing harassing and 
even agonizing pain, and extremely sensitive to pressure, develop in the 



234 THE HEAD, FACE, AND NECK 

early period of secondary syphilis, appearing at times even before the 
exanthemata. 

Gummata of the scalp are characterized by small copper-colored, 
usually painless, nodules, which, in the absence of treatment, break 
down, forming small, punched-out, wormeaten, indolent ulcers, rounded 
in shape, grouped, sometimes confluent. They are commonest in 
the frontal region near the hair line and on the top of the head. The 
persistence of an ulcer in these regions is in itself suggestive. 

Distinction from a non-ulcerating sebaceous cyst is difficult in the 
absence of a history. 

Gummata of the cranial bones, affecting chiefly the frontal and parietal 
region, and developing in the third year of the disease or much later, 
are often characterized by agonizing, generally local, pain, which becomes 
worse toward evening. 

When the infiltration is pericranial, one or many small dense tumors 
may be felt through the scalp, which at first is perfectly normal, and 
freely movable over them. These tumors may disappear, leaving 
distinct depressions in the bone, or, the scalp becoming adherent, they 
may ulcerate and discharge a gummy pus. Dead bone can be felt by 
probing the sinuses, but sequestra, which may be extensive, show little 
tendency to separate. Together with the destructive process there 
is a formative one, the bone becoming thicker about the lesion and 
exostosis developing. 

Gummata which develop from the dura mater are marked by pain 
more intense than that which accompanies the pericranial infiltra- 
tion, vertigo, poor mentality, and later by convulsive seizures which 
may be general or focal, and partial palsies. Should the gumma soften, 
break through the cranial bone, and form a fluctuating, partially reducible 
tumor, the diagnosis would be obvious. This penetration is rare. 

The history of an hereditary or acquired infection, the presence of 
other syphilitic lesions or their traces, the induration preceding ulcera- 
tion, the seat of the lesions, the age of the patients, the chronic course, 
the persistence of the sequestra, the anfractuous borders of the osseous 
lesions, the absence of febrile reaction, and the prompt effect of specific 
treatment are features which characterize the cranial lesions of syphilis. 

Tuberculous lesions, in addition to being much rarer, affect children 
who usually show other unmistakable lesions of tuberculosis. The 
sequestra often come away spontaneously and there is no exostosis or 
other formative process about the borders of the lesion. 

The ulcerating gummata of hereditary syphilis, commonly placed 
about the bregma, are much commoner than are the tuberculous infiltra- 
tions in this region. 

Acute suppurative osteomyelitis is evidenced first by the sudden 
onset of an agonizing headache, local tenderness to tapping and deep 
pressure, the constitutional symptoms of violent sepsis, and local edema 
which shordy becomes diffuse and exhibits the softening of suppura- 
tion. This acute bone infection, commonest during or before adolescence, 
is usually secondary to wounds or contusion, but may occur without 



THE HEAD 235 

appreciable cause. Its violent onset and rapid progression are char- 
acteristic. 

From a localized meningo-encephalitis the diagnosis in severe cases 
may be impossible, probably because this is a common complication. 

With the exception of the pachymeningitis of sunstroke, alcohol, or 
syphilis, characterized chiefly by persistent headache lasting months or 
years, it may be assumed that the encephalon is more or less involved 
in all inflammations of its envelope. 

Acute Leptomeningitis. — Acute leptomeningitis, traumatic, second- 
ary to an infection of neighboring structures or of systemic origin, is 
usually inaugurated by intense headache, chill or vomiting, or both, 
rapid pulse and high fever, often hypersensitiveness of the special senses, 
muscular twitchings, and active delirium or a condition of apathy or 
somnolence. The most characteristic features of the affection are either 
general or local contractures, particularly of the postcervical group of 
muscles, keeping the head back and rigidly extended, and convulsions, 
followed by paralysis, which may be local and thus localizing. In pro- 
gressive cases the delirium or somnolence is succeeded by coma, irregular, 
hurried pulse, and disturbed, often Cheyne-Stokes, respiration. The 
course of the affection in its ordinary surgical form is rapid. Pronounced 
temporary improvement followed by relapse is not uncommon. 

The development of rigidity of the postcervical muscles and paralysis 
of the facial, the oculomotor, or the abducens nerve point to a basilar 
meningitis. 

In framing the diagnosis, a history of a preceeding contusion or com- 
pound fracture is of importance. The absolute diagnosis not only as 
to the presence of meningitis, but the form of infection producing it, 
can usually be made by lumbar puncture. High fever and leukocytosis 
are suggestive but not absolutely diagnostic of the non-infectious serous 
form of acute leptomeningitis. 

Secondary leptomeningitis, exceptionally consequent to suppurative 
lesions of the scalp or the cranial bones, is particularly likely to com- 
plicate osteomyelitis, mastoid disease, or suppuration of the middle ear 
or infection of the frontal, ethmoidal, or sphenoidal cells. It occurs 
in the course of pyemia, pneumonia, typhoid, or any general infection. 
The symptoms do not differ from those already given. 

Tuberculous meningitis (p. 202) is characterized by a prodromal period 
of ill health and the absence of a sufficient traumatic or local infective 
cause. Its development in early childhood, or, if in adult life, its practi- 
cally invariable association with tuberculous lesions of other parts of the 
body, its almost constant association with strabismus, irregularity of 
the pupils, optic neuritis, and other eye symptoms, and its comparatively 
slow progress, are characteristic features. The diagnosis is based upon 
examination of the fluid obtained by lumbar puncture. 

Inflammation of the Dural Sinuses. — This is rarely primary, i.e., 
incident to direct infection of a thrombosed vessel through a fracture. 
It is usually secondary to infection of the orbit, sphenoidal or ethmoidal 
sinuses, or the tympanum and mastoid cells. 



236 THE HEAD, FACE, AND NECK 

The characteristic features of infection of the lateral sinuses are: A 
history of chronic ear trouble, the sudden onset of vomiting, fever (the 
latter often preceded by a chill and headache), marked fluctuations of 
temperature and recurrence of rigor or chills, edema and tenderness, 
both over the mastoid and in the neck along the course of the internal 
jugular vein, a condition of venous stasis in the scalp of the temporal 
and occipital regions, tenderness and perhaps edema elicited by deep 
pressure below the external occipital protuberance and posterior to the 
mastoid process, some stiffness of the neck muscles, and often optic 
neuritis. Exceptionally there is irritation or palsy of the hypoglossal, 
glossopharyngeal, and spinal accessory nerves, or even of the pneu- 
mogastric. It will be noted that the symptoms are those of septicemia 
or pyemia, combined with those of meningeal irritation. Metastatic 
abscesses are likely to develop early in the lung. 

Thrombosis (septic) of the cavernous sinus, secondary to suppuration 
of the orbit, or of the sphenoid or ethmoid cells, is characterized by 
the sudden onset of septic symptoms, as in the case of thrombophlebitis 
of the lateral sinus, together with congestion and edema of the retina, 
swelling about the forehead and eyelids, usually exophthalmos, and 
paralysis of the third, fourth, and the ophthalmic branch of the fifth 
nerve. 

Infection of the superior longitudinal sinus is secondary to traumatic 
infection of the adjacent tissues. The only suggestive localizing sign 
which it might give would be a tendency to nose-bleed, and edema and 
venous congestion along the course of the sinus. 

Abscess of the Brain. — Abscess of the brain is characterized by 
a preceding history of middle ear disease or of trauma, particularly 
that incident to penetrating punctured wounds. Abscess is manifested 
by headache, which may be unilateral, mental asthenia and irritability 
with somnolence and stupor, percussion tenderness at times, surface 
heat as shown by the surface thermometer, a normal or even subnor- 
mal temperature, with occasional slight transitory rises associated with 
a slow, sometimes intermitting, pulse; rigors, vomiting, constipation, 
possibly unequal pupils, and occasionally optic neuritis. If the abscess 
is situated in the psychomotor centres, or so near as to affect them, 
its localization is made possible. 

Post-traumatic abscesses, if developing within a few days of injury, 
are usually completely masked by the associated meningo-en cephalitis. 
Their presence, however, might be suspected were clearly marked focal 
symptoms to develop early. If, after an interval of weeks, months, or 
even years, pain with remissions, mental inaptitude, irritability, and 
torpor, and the symptoms just detailed were to develop, the possibility 
of intracranial abscess should be considered. 

Abscess secondary to middle ear disease may present, if cerebral, in 
addition to the symptoms characteristic of intracerebral abscesses in 
general, a history of chronic middle ear disease, often peripheral facial 
palsy, aphasia, twitchings, rigidity or palsy of the arm of the side 
opposite to the lesion, or hemiplegia or hemianesthesia. 



THE HEAD 237 

Such an abscess, if cerebellar, might be marked by staggering gait, 
vertigo, and obstinate vomiting. 

An abscess may develop without any localizing symptoms, exception- 
ally without the general symptoms of septic absorption, cerebral irrita- 
tion, or pressure, until by rupturing into the ventricles it suddenly causes 
convulsions, coma, and death, or, reaching the meninges, sets up an 
acute diffuse meningo-encephalitis. 

Secondary to middle ear disease, meningo-encephalitis, sinus throm- 
bosis, and abscess are about equally common. All are characterized 
by similar symptoms. Moreover, acute inflammation of the middle 
ear or mastoiditis with retention of pus will cause fever, rapid pulse, 
severe pain, and often delirium, with symptoms of slight meningeal 
irritation. 

A differential diagnosis maybe formulated by considering that meningo- 
encephalitis is violent in onset and rapid in course, and is evidenced 
by high fever, rapid, often irregular, pulse, strabismus, and often stiffness 
of the jaws and the back of the neck. 

Thrombosis of the lateral sinus is attended with marked edema and 
swelling about the ear, especially behind it, and sometimes involving 
the entire head on the afi^ected side ; it may exhibit tenderness and indura- 
tion along the course of the internal jugular vein and choked disk. The 
symptoms shortly become profoundly septic, with the chills, fever, and 
sweats of this condition, and the rapid pulse and metastatic deposits 
occur early. Intracranial abscess is characterized by a slow pulse, 
and subnormal or but little above normal temperature, by dulled men- 
tality, often aphasia, vertigo, and signs of irritation or compression of 
cortical motor and sensory areas in the brain. 

Acute otitis media and chronic mastoiditis with retention are character- 
ized chiefly by pain and its systemic effect, nor is there the appearance 
of serious illness which characterizes the intracranial infections. 

When it is impossible to distinguish between these conditions, and 
this is often the case, since two or more are commonly associated, the 
diagnosis must be made by exploratory operation above the middle of 
the bony meatus (measured vertically from Reid's base line, i. e., a line 
passing from the lower orbital margin through the middle of the bony 
meatus). Through this opening a probe may be passed between the 
dura and the roof of the tympanum ; by enlarging this opening upward 
and backward for about 2 cm., access to the temporosphenoidal lobe 
is facilitated. 

In the absence of extradural or subdural pus, or pronounced subdural 
serous effusion, the substance of the brain is explored by either a grooved 
director or an aspirating needle with a canal of at least 1 mm. caliber.. 
The hypodermic syringe is inadequate, since the thick pus of cerebral 
abscesses will not pass through its fine canal. The direction of explora- 
tion from a point 3 cm. above and 3 cm. behind the bony meatus is 
downward, forward, and inward. 

The lateral sinus is reached by a trephine opening tangent, in its 
lower periphery, to Reid's base line, and an inch (2.5 cm.) behind the 



238 THE HEAD, FACE, AND NECK 

middle of the bony meatus. A hypodermic needle thrust into the sinus 
will show the presence or absence of fluid blood; in the latter case the 
sinus should be opened. 

The cerebellum is reached through a trephine opening tangent to 
Reid's base line in its upper segment and placed 4 cm. behind the middle 
of the bony meatus. The direction of exploration into the cerebellar 
substance should be upward, forward, and inward. 

From neoplasm, fungus may be distinguished by its direct, almost 
immediate, relation to trauma or suppuration and by microscopic 
examination. 

Tumors of the Scalp and Cranium. — Superficial growths which 
originate in the skin or beneath it, and move with the scalp, are angioma, 
or birthmark, wart, sebaceous cyst (may become adherent from inflam- 
mation), lipoma, gumma, epithelioma, sarcoma, fibroma, keloid, lymph- 
angioma, neurofibroma, enchondroma, and osteoma. 

The growths not moving with the scalp attached to the bone and in 
their early development of dense consistency are gumma, exostosis, 
tuberculoma, and osteosarcoma. Tumors not movable over the peri- 
cranium and fluctuating from the first are subcranial cephalhematoma; 
dermoid cysts; if partly or wholly reducible, meningocele, perforating 
tuberculous abscess, or blood cyst communicating with a sinus. 

Verruca. — Verrucse, or warts, of the scalp are common in elderly persons. 
They are usually single, exceptionally they are multiple and confluent, 
and a large area of the scalp may be covered by the hyper trophied 
papillae. From their position these warts are subject to recurring irrita- 
tion, they bleed readily, become ulcerated, and are frequently the starting 
points for epitheliomatous degeneration. Before such transformation 
they cannot well be mistaken for any other lesion. 

Angioma. — ^The head is a favorite seat for vascular tumors. They 
are usually congenital, though the lesion may be so slight at birth as to 
escape notice. They are characterized by red, purple, or deep brown 
discoloration of the skin, often associated with a growth of hair. From 
them sarcoma may develop, and lipoma and flbroma sometimes accom- 
pany them. 

In its slightest form the angioma appears as a red splash upon the 
skin. When the arteries and veins participate markedly in the dilata- 
tion, a soft, depressible, purple, flat or rounded tumor is formed, usually 
in the frontal and temporal regions of an infant. This tumor can be 
emptied by pressure, and if, after it is emptied, a ring is pressed firmly 
about the growth the blood will reaccumulate very slowly. 

In the deep form placed beneath the temporal aponeurosis a heman- 
gioma forms a soft, sometimes pulsating tumor, which becomes dis- 
tinctly larger during crying efforts and on placing the head in a 
dependent position. The diagnosis is usually dependent upon asso- 
ciated angiomatous manifestations in the skin. Meningocele is not 
likely to be found in the temporal region. 

Cirsoid aneurysm, commonly an affection of early adult life and 
usually affecting the temporal and parietal regions, forms a flat, 



THE HEAD 239 

pulsating tumor, made up of many dilated and tortuous arteries, the 
course of which can be both seen and felt. The overlying skin is 
thickened and purplish in color. 

Arterial aneurysm, usually traumatic and rare since the days of 
phlebotomy, is marked by the development of a pulsating tumor, 
usually in the course of the temporal artery, which gives thrill and inter- 
mittent bruit, and partly or completely disappears when pressure is 
made in the arterial trunk proximal to the tumor. 

Arteriovenous aneurysm develops in the temporal and the frontal 
region as a flattened, pulsatile tumor with bosselated surface because of 
the dilated veins. Thrill, expansile pulsation, and constant murmur, 
often harsh and loud, with exacerbations synchronous with the systolic 
impulse, are present. It is distinguished from cirsoid aneurysm by its 
traumatic origin, the absence of skin pigmentation or alteration, and the 
fact that pressure at the point of communication between artery and vein, 
stops the bruit and pulsation. The venous dilatation may be widespread. 

A blood tumor communication with a dural sinus forms a small, 
rounded, soft, or fluctuating tumor, usually in the course of the superior, 
longitudinal sinus. It is chiefly characterized by the fact that it is 
reducible, and is made tense by straining efforts or a dependent posi- 
tion of the head. Exceptionally after reduction the bony opening may 
be felt. The tumor may be congenital, traumatic, or without assignable 
cause. It gives neither pulsation nor bruit. 

Elephantiasis. — Elephantiasis in the few cases observed has affected 
the skin of the scalp in the occipital region forming a pendulous flap 
of coarse, greatly thickened, indurated skin. 

Fibroma. — Fibroma, in its superficial hard form, appears as keloid, a 
dense, smooth, pink or white, raised, commonly painless induration 
about a scar, distinctly outlined, throwing out claw-like projections 
into the surrounding healthy skin. In its soft form the fibroma forms 
an infiltration into and beneath the skin. It is often multiple, involving 
not only the scalp but other parts of the body. The tumors may be 
extensive, forming pendulous flaps, or may appear as small, single, or 
multiple infiltrations. 

Neurofibroma of the scalp is characterized by the development of a 
soft, nodular, sometimes very extensive tumor. The nerve or nerves 
affected are tortuous, beaded, and tender. This is particularly marked 
about the periphery of the swelling, the skin and subcutaneous tissue 
being greatly thickened about the centre. The skin may be freely 
movable over the neuromatous nodules, these in turn being movable 
over the scalp. This tumor presents the appearance of a thickened, 
hypertrophied, sometimes pigmented, and hirsute flap of skin; its seat 
of election is the side of the head. 

Fibrolymphangioma, appearing first as a small soft infiltration of the 
occipital region, when well developed becomes more or less pedunculated, 
presenting a vermiform surface suggesting the presence of dilated and 
tortuous vessels. This tumor is always intimately adherent to the skin 
and does not exhibit the nodulation of the fibroneuromata. 



240 



THE HEAD, FACE, AND NECK 



Lipoma. — A rare scalp tumor shows a predilection for the forehead 
just external to the upper part of the frontal protuberance at the part 
where the hat brim presses. It forms a soft, rounded tumor which 
closely resembles a sebaceous cyst. Lipomata, probably congenital 
in origin, may grow beneath the temporal fascia, forming elastic swell- 
ings which may reach great size. These growths commonly develop in 
middle life (Chipault). 

Wens, or Sebaceous Cysts. — ^These are characterized by the develop- 
ment of one or usually many raised, rounded, tense, semifluctuating, 
non-inflammatory tumors of varying sizes, from 5 cm. to 10 cm. in 
diameter, adherent to the skin in their central part, and sometimes 

Fig. 86 




Wens. Many years' duration; movable, non-sensitive, hard. 

exhibiting the dilated aperture of a duct from which sebaceous matter 
can be squeezed out. The adhesion to the skin is often difficult to 
detect in small tumors which have not been inflamed or exposed to 
pressure. Nor can the duct leading to the accumulation of sebaceous 
matter usually be found. Most tumors grow slowly. When they 
become irritated and infected the symptoms are those of abscess. After 
evacuation of pus and sebaceous matter there is often left a sinus or an 
ulcerating surface with indurated borders strongly suggesting gumma 
or epithelioma. Malignant infiltration may take its starting point from 
an inflamed sebaceous cyst. These cysts are commonest in women 
at or past middle life. 



THE HEAD 



241 



Epithelioma, or Skin Cancer. — Epithelioma, commonly beginning as a 
chronically inflamed wart, patch of keratosis, or sebaceous cyst, is 
characterized by ulceration which is persistent and slowly (months, 
years) progressive. Young people are not entirely exempt. The fore- 
bead and the parietal region are the points of election. The lesion may 



Fig. 87 




Epithelioma of scalp. Chronic sloughing vdcer, irregular in outline, with elevated borders and 
infiltrated reddened areola. Six months' duration. Second point of ulceration beginning at lower 
periphery of the neoplasm. 



appear as a punched-out ulcer which has destroyed everything in its 
course, even the bone, unaccompanied by lymphatic involvement, and 
exhibiting a very narrow area of induration about its purple, ragged 
edges. This form, the rodent ulcer, is slow, lasting for years, and pro- 
ducing appalling deformities. 

The epitheliomata characterized by pronounced induration and by 
f ungating granulations and lymphatic enlargements are rapidly fatal. 
16 



242 THE HEAD, FACE, AND NECK 

Senile epithelioma may begin as a hard, cutaneous or subcutaneous, 
vascular, purplish nodule. 

Persistent scab formation and induration of any scalp lesion in an 
elderly person should always suggest epithelioma. If syphilis can be 
ruled out, the diagnosis should be made immediately by wide excision 
of the inflammatory lesion and examination with the microscope. 

The cutaneous and subcutaneous gummata, in both their formative 
and ulcerative stages, may resemble the infiltration of epithelioma. 
These lesions are, however, fairly rapid in course (weeks), show no 
peripheral infiltration, do not involve lymphatic glands, are painless, 
yield to specific treatment, and are associated with a history of syphilis 
or other signs of the disease. 

Tuberculosis in the form of lupus begins in early life, exhibits multiple 
lesions, no induration, no lymphatic enlargements, is less deeply destruc- 
tive, and exhibits the peripheral jelly-like nodules. 

Osteoma and Chondroma. — Osteoma and chondroma have both been 
observed free from the bones of the skull and movable with the scalp. 
The nodulated hardness of these tumors would suggest their structure. 

Usually these tumors are fixed to the cranium, exhibiting hard, flat 
or rounded, single or multiple, sessile or pedunculated outgrowths, often 
post-traumatic. 

They may be external or internal or may project from both surfaces 
of the cranial bones. The internal osteomata are, since they rarely 
reach large size, usually symptomless. 

Sarcoma. — Sarcoma of the scalp is characterized by the rapid develop- 
ment of a soft, vascular, semifluctuating tumor. The growth may be 
metastatic, extend from the dura through perforated bone, or may 
originate in an angioma of the skin or beneath it. In the latter case 
it may be pigmented and smaller tumors may form about the central 
one. The superficial sarcomata erode the bone, forming a direct com- 
munication with the interior of the skull. They are often pulsatile. 

Sarcoma of the cranial bones, frequently post-traumatic, may at first 
be hard and nodular; later, in the myelogenic forms as the covering 
shell of bone is thinned, there is crackling on pressure, as of a broken 
eggshell. There is at times severe pain. The major symptom is tumor 
which in the beginning exactly simulates gumma and grows about as 
rapidly. The diagnosis should be made by removal and examination 
if syphilis can be excluded. The rapid growth of an osteoma should 
suggest sarcomatous degeneration. 

Of the soft, fixed, irreducible tumors of the cranium, sebaceous cyst, 
which has become adherent from inflammation and erosion, is recognized 
by the history of its development and its long standing. Gummata 
sometimes form flat or rounded, boggy, painful swellings on the frontal 
and parietal regions, accompanied by severe pain. The diagnosis is 
based on the history and the therapeutic test. Pain and tenderness are 
well marked. 

Encapsulated, translucent serous cysts, sometimes found in the occipital 
region, are probably the remains of a true meningocele. 



THE HEAD 243 

Cystic sarcoma which has perforated the cranium from without 
inward is characterized by its large size, the dilated veins overlying 
and surrounding it. Perforating sarcomas from the dura in their later 
stages are neither pulsatile nor reducible. 

Cephalocele. — Cephalocele, or projections of the brain and its mem- 
branes through congenital bone defects of the skull, are usually flaccid, 
sometimes tense tumors, springing from the midline in the frontal 
occipital region. When not obscured by overlying lipomatous or angio- 
matous growths, these protrusions form smooth, rounded, sometimes 
large, or fluctuating reducible tumors which become tense when the 
child cries. 

Encephalocele (rare) made up of brain substance without cystic 
formation usually occupies the frontal region and forms a soft elastic 
swelling which is generally pulsatile, partly reducible, causing pressure 
symptoms when this is attempted, and becomes larger on straining 
efforts. This growth is not translucent. 

Encephalocystocele, the usual form of tumor, in which there is brain 
substance and within this a cavity containing cerebrospinal fluid, may 
be small or large. The occipital region is the seat of preference. The 
brain substance may be so attenuated in the walls of the lumen that 
translucency is obvious. 

Cephalocele may project into the orbit, nose, pharynx, or mouth, 
and has been mistaken for nasal or pharyngeal polyp. 

True meningocele is rare. 

Angioma, if placed in the midline, may, because of its apparent 
reducibility by pressure and its change in size and lumen incident to 
crying or straining, simulate cephalocele. 

Dermoid Cysts. — A congenital tumor which may develop in adult life 
is evidenced by the growth of a rounded tense tumor which exhibits 
a predilection for the upper midforehead and outer orbital regions. 
It is adherent to the bone below, and in the latter there may be felt 
a depression. This tumor closely resembles a sebaceous cyst. Its 
adhesion to the skull and its development in infancy and early child- 
hood would aid in forming a diagnosis. An intracranial dermoid would 
give only the symptoms of local or general pressure. 

Pneumocele of the Scalp. — Pneumocele of the scalp is characterized 
by resonance on percussion and reducibility by pressure. It may 
develop on the frontal or the supramastoid region, and is due to a trau- 
matic or pathological opening into the frontal or the mastoid cells. 
After these cysts are emptied they can again be filled by holding the 
nostrils and attempting to blow through the nose. They may gradually 
attain large dimensions and may be subaponeurotic or subperiosteal. 

Hydrocephalus. — Hydrocephalus may be congenital or acquired. In 
its congenital form, frequently associated with syphilis, rickets, cephalo- 
cele, or spina bifida, it is characterized by a disproportion in size 
between the cranium and face incident to overdistension of the ventricles 
with fluid and consequent yielding of the cranial walls. The sutures 
and fontanelles are thus prevented from closing. The soft, bulging, 



244 



THE HEAD, FACE, AND NECK 



heavy head, with its enlarged veins; the small face, raised eyebrows, 
and projecting displaced eyeballs are characteristic at a glance. 

Acquired hydrocephalus, symptomatic of obstruction from inflamma- 
tion or tumor, if it develops after the period when the skull is closed, will 
be characterized by the stupor of cerebral pressure, often by muscular 
rigidity expressed in the extremities. The condition is usually over- 
shadowed by the symptoms of the causative lesion. The diagnosis may 
be made by ventricular puncture. 

Microcephalus. — Microcephalus, or abnormally small head, secondary 
to congenital malformation of the brain, if pronounced, is obvious at a 
glance. Normal variations are so great that it is often difficult to decide 
when the pathological has been reached. Surgical enthusiasm and 
belief in the efficacy of operative measures has no doubt led to the detec- 
tion of a microcephalus which would otherwise not have been observed. 
Exceptionally early closure of the sutures is noticed. These cases are 
characterized by persistence of the infantile state. 



THE FACE. 



Malformations. — Harelip, partial, complete, or double, often asso- 
ciated with partial or complete palatal cleft, is the common malforma- 
tion. It is sometimes associated with symmetrical tumors placed hear 
the midline of the lower lip and discharging each from its duct a salivary 
fluid. 

Fig. 88 




Single harelip. Deformity of nose in excess of average case. (University Hospital.) 

Other congenital deformities, such as lateral or mesial nasal cleft, 
oblique facial cleft, clefts in the cheeks, or median cleft of the lower lip 
or under jaw, are extremely rare. 



PLATE XIII 




Lupus Erythematosus. (Hartzell.) 



THE FACE 



245 



Fibrocartilaginous skin tabs upon the cheeks and neck near the ear 
are not uncommon. 

Contusion. — The rapid swelUng following contusion may cause 
underlying fracture of the bones of the face to be overlooked. The 
zygoma, the orbital ridge, the nasal bones, and the maxillae should be 
carefully palpated when injury is so applied as to endanger these 
structures. Emphysema is diagnostic of a fracture of the nose or of 
the walls of the nasal sinuses. 

Fracture of the malar bone is occasionally characterized by a depression 
of the zygoma. The deformity may be elicited by careful palpation, 
even when there is an extensive overlying blood effusion. This is also 
true of fracture which has driven in the anterior antral wall. 



Fig 




Cleft palate and harelip. 

Skin Lesions. — The skin of the face is subject to a multiplicity of 
lesions of which the commonest are acne, comedo, milium, seborrhea, 
the various manifestations of the exanthemata, erythema, herpes, urti- 
caria, syphilides, impetigo contagiosa, dermatitis venenata and medi- 
camentosa, erysipelas, eczema, recurrent hydroa puerorum, xanthoma, 
tinea, angioma, lymphangioma, fibroma, lupus, and epithelioma. 

Acute Inflammatory Affections of the Face.— Furuncle. — Furuncle, 
though it may occur in any part of the face, has its seat of preference 
in the upper lip and the inner aspect of the nasal orifice. It may be 
characterized by edema, pain, tenderness, induration, and constitutional 
symptoms of infection much more pronounced than are caused by the 
lesion in other parts of the body. 

Carbuncle. — Carbuncle, a conglomeration of furuncles, is accompanied 
by pronounced local and constitutional symptoms of inflammation. The 
redness and edematous swelling may be so widespread as to suggest 
erysipelas. It occasionally terminates fatally in a few days by septic 
thrombosis and meningitis, extending from the orbit to the cavernous 



246 THE HEAD, FACE, AND NECK 

sinus. Dilatation of the veins about the orbit, exophthalmos, chemosis, 
and profound sepsis out of proportion to the local lesion would suggest 
such an extension. Even in favorable cases there may be extensive 
tissue necrosis. 

Maligant Pustule. — Malignant pustule is characterized by a burning 
nodule, surmounted by a discolored vesicle which bursts and forms a 
broAvn scab, about which secondary vesicles form and rupture, leaving 
a surface of ulceration. The swelling spreads rapidly, quickly involving 
the associated lymph glands, and in one or two days constitutional 
symptoms of severe septic infection develop. The diagnosis of anthrax 
is based upon the presence of the vesicles and their dissemination and 
the finding of the characteristic bacillus (p. 76). 

Glanders. — Glanders, usually primary in the mucous membrane of the 
nose or throat, may attack an abrasion or wound of the skin of the face, 
running through an acute or chronic course. It forms characteristic 
ulcerating nodules, and is diagnosticated by the detection of the bacillus 
mallei (p. 77). 

Erysipelas. — Erysipelas commonly begins in a surface break about the 
opening of the nostrils or the lips and sweeps over the face to the hair 
line and often beyond. It is usually superficial in type and accompanied 
by great swelling, redness, slight vesication, glandular involvement, and 
marked constitutional symptoms of sepsis. It is often inaugurated by 
vomiting. It lasts about a week, but may clear up in a day or not for a 
month. Its peripheral, rapidly extending, raised border, representing the 
seat of greatest inflammation is characteristic (p. 75). 

Noma. — Noma is characterized by the development of an acute gan- 
grenous process, beginning as a dirty white patch on the gums or inner 
surface of the cheek and rapidly (hours or days) causing extensive 
destruction of both bone and soft parts. A streptothrix is constantly 
found. It develops in anemic children after measles and scarlet fever, 
rarely in sucklings or adults. It is characterized in its early develop- 
ment by extensive infiltration, an apparently superficial erosion of the 
inside of the buccal mucous membrane being attended with a thick 
hardness of the cheek and a dusky discoloration of the overlying skin. 

Acute Lymphadenitis. — Acute lymphadenitis, suppurative in type, not 
infrequently develops in the gland lying in the front of the ear, in one or 
more of the group lying in the cheek, or in that placed on the outer border 
of the body of the jaw, forming an abscess much like a furuncle, except- 
ing that it is preceded by a hard, tender tumor formed by the inflamed 
gland, causes a more extensive swelling and redness, and the involve- 
ment of the skin is secondary. 

Angioneurotic Edema. — Angioneurotic edema, usually mistaken for the 
bite or sting of an insect, is common on the face, particularly in the 
region of the upper lip, is marked by a sudden swelling, commonly 
noticed on rising in the morning, accompanied by some heat and burning 
pain. It subsides in a few hours or at most one or two days. The 
diagnosis is based upon the sudden, causeless onset, its transitory nature, 
and the very slight accompanying inflammatory phenomena. 



PLATE XIV 




Lymphatics and Lymph Nodes of the Face. 



THE FACE 



247 



Acute swelling of the face may be due to inflammation of the under- 
lying bones or their cavities. Osteomyelitis of the jaws incident to 
carious teeth, or occurring as a local expression of general infection (p. 
284) or inflammation of the maxillary or frontal sinuses, is the common 
cause of this secondary swelling. 

Chronic Ulceration of the Face. — Tuberculosis. — Lupus has for the 
seat of predilection tlie face. It begins in early childhood, or at least 
before puberty. It is often associated with other manifestations of 
tuberculosis. 

The disease first appears in the form of small brownish nodules 
about the nose, cheeks, chin or lips, or forehead. It is extremely chronic 
(years), and extends by slow destructive ulceration, cicatrization going 
on at the same time. There is a non-ulcerative form characterized by 
the development of scar tissue. The ulcerative form reaches the under- 
lying bony or cartilaginous framework, causing deforming cicatrices. 
It commonly spreads to the mucous membrane. The lymph glands 
are often involved. The scar tissue is subject to malignant degeneration. 

In certain proliferating or de- 
structive forms of lupus, the 
lesions may closely resemble car- 
cinoma or gumma. The history 
of the case, its extremely slow 
course, and the finding of the 
brownish pinhead-sized nodules 
will aid in making the diagnosis. 

Tuberculous Sinus. — Tubercu- 
lous sinus may form on the face 
as the result of the breaking- 
down of a lymph node or sec- 
ondary to involvement of the 
facial bones. The gland in front 
of the ear is the one which com- 
monly suppurates. Its painless, 
non - infiammatory enlargement 
precedes softening, and is usually 
accompanied by characteristic in- 
duration of the submaxillary 
group. The second common seat 
of sinus formation is in the mid- 
dle of the cheek, or lower down over the body of the jaw secondary to 
tuberculous caries of the bone, commonly found at the outer border 
of the orbit. A painless, fluctuating swelling forms. On opening this 
the characteristic cheesy pus is discharged and necrosed bone can be felt. 

Chancre. — Chancre, commonest on the upper lip, may be found on 
any part of the face, is characterized by its comparatively rapid and 
relentless development (one to three weeks), the absence of acute inflam- 
matory symptoms, induration, and the early and pronounced enlarge- 
ment of the associated lymph glands. It is often accompanied, especially 




Tuberculous sinus of cheek preceded by indura- 
tion and softening of mouth gland. 



248 



THE HEAD, FACE, AND NECK 



on the lips, by pronounced edema, and may reach a size much larger 
than is characteristic of it when it develops upon the genitalia. This 
is particularly true of chancre of the cheek. It so closely resembles 
epithelioma that it has more than once been excised on the basis of 
this diagnosis. However, it attains a size and development in two 
weeks not reached by the epithelioma in as many months. 



Fig. 91 




Chancre of cheek. Duration, weeks. Painless, indurated, marked enlargement of submaxillary 
glands. Healed with very slight scar. (Hartzell.) 



Papular and pustular syphilides, especially when they occur about 
the nose and lips, may closely resemble lupus, but are characterized by 
their much more rapid development associated with the history of 
syphilis and the effect of constitutional treatment. 

The lesions of hereditary syphilis are more difficult to differentiate; 
their destructive effect is more manifest upon the bones of the nose than 
are those of lupus. 

Gummata of the Face. — ^Gumma of the face is characterized by pain- 
less infiltration, which, untreated, breaks down rapidly (weeks), forming 
rounded, punched-out, non-indurated ulcers, unaccompanied by glandu- 



Fig. 92 




Syphilitic necrosis of the bones and cartilages of the nose. Gumma of forehead (frontal bones) 
and of chin (skin and subcutaneous tissues). 

Fig. 93 




Circinate syphilide. (Hartzell.) 



250 



THE HEAD, FACE, AND NECK 



lar enlargement. They occur about the nose, hps, and forehead, and by 
confluence may produce extensive destruction of both soft parts and the 
underlying bone and cartilage. They are distinguished from carcinoma 
by the history of syphilis where this is obtainable, their rapid destructive 
course, absence of induration, and absence of glandular involvement. 
Gumma causes in weeks, exceptionally in days in the hyperacute form, 
destruction which epithelioma may not accomplish for months or years. 
Actinomycosis.^ — Actinomycosis of the face is usually secondary to 
infection of the jaw. It is often associated with the inflammation 
incident to a carious tooth. As elsewhere, it is characterized by extensive 
induration and the development of one or more sinuses (p. 76). 

Fig. 94 




Epithelioma. Duration, years. No glandular involvement. (Hartzell.) 



Epithelioma. — Epithelioma, commonest on the lower lip of middle- 
aged and old men, usually begins in a spot of leukoplakia about the lips 
or in pigmentations, seborrheic scales, patches of keratosis, or warty 
growths about the face. 

The flat form (rodent ulcer), particularly common about the fore- 
head, temple, and nose, forms at first a crust beneath which lies a super- 
ficial ulcer which exhibits a cicatricial tendency, drawing the skin into 
fine radiating wrinkles. The growth may remain small, superficial, 
and stationary for many years, or may gradually extend in all directions. 



THE FACE 



251 




J 



/ ^^,M 



> 



\ 




involving not only the soft parts, but the bones beneath, producing 
extensive destruction. The glands are not involved. 

The fungating form, common about the lower lip, begins as an indura- 
tion or as a persistent crusted ulcer which extends in all directions 
(months), is fungating, infiltra- 
ting, and destructive, and is Fig. 95 
attended by early gland involve- ^ "tT'-^T"— - ^- ^ 
ment. 

The diagnosis of cancer of the 
face is based upon the presence 
of a persistent or recurring ul- 
ceration which is neither syphi- 
litic nor tuberculous. It should 
be formulated while the ulcer is 
still small by excision under local 
anesthesia and microscopic ex- 
amination. The fully developed 
lesion can be recognized across 
a public square, but the diag- 
nosis is no longer serviceable. 

Affections Characterized by 
Tumor of the Soft Parts with- 
out Inflammatory Phenomena. 
— Lipoma . — Lipoma (rare) , whc n 
subcutaneous, exhibits the char- 
acteristic features of this growth. 
Exceptionally, it grows from the 
pad of fat lying along the ante- 
rior border of the masseter mus- 
cle, forming an obscurely fluc- 
tuating tumor projecting either externally or within the mouth. Diag- 
nosis will be suggested by the extremely slow growth, but must be made 
by incision. 

Fibroma. — Fibroma is often congenital, forming flat, wart-like indura- 
tions, associated with pigmentation, capillary dilatation, and local growth 
of hair. These growths may slowly increase, forming in the course of 
years pendulous and deforming flaps. The plexiform neurofibroma 
(congenital) involves the skin and underlying tissues in a highly character- 
istic nodular growth. 

Hemangioma. — Hemangioma, present at birth, affecting by preference 
the faces of girl babies, in its capillary form appears as a red blotch, made 
more prominent by crying, often associated with pigmentation and over- 
growth of hair. Its growth may be commensurate with the general 
increase in size of the body or it may extend with great rapidity. 

Cavernous hemangioma forms a typical, soft, ill-defined, dark bluish 
tumor which may be reduced by pressure and which increases in size 
from cephalic congestion. This growth is commonly associated with 
diffuse fibroma, and may cause great deformity. When placed beneath 
the temporal or the occipitofrontal fascia it may simulate meningocele. 



Epithelioma. (Von Bergmann's clinic.) 



252 



THE HEAD, FACE, AND NECK 



Racemose angioma (rare) exhibits pulsation and dilated and tortuous 
bloodvessels. 

Lymphangioma. — Lymphangioma forms diffuse, pasty infiltrations 
covered by normally colored skin, usually congenital, sometimes cystic. 
This dilatation of lymph vessels, often associated with hemangioma and 
fibrous infiltration, is the common cause of macroglossia and macrocheilia. 

Sarcoma. — Sarcoma of the skin and underlying soft tissues of the face 
is marked by its rapid growth. Congenital multiple forms have been 
described. The orbit is the common seat, and it is distinguished by 
its rapid growth and prompt metastasis. 



Fig. 96 




Tricho-epithelioma. Benign cystic epithelioma. (Hartzell.) 

Diagnosis should be based upon the excision and examination of an 
apparently causeless inflammation or enlargement of a mole or a pig- 
mented spot, or the appearance of a tumor not obviously benign. 

Sebaceous Cyst. — Sebaceous cyst, comparatively rare in the face, 
forms a small, hard, shining, round growth in the skin, often with a 
central aperture. It may become acutely inflamed or undergo calcifi- 
cation or malignant degeneration. 

Dermoid. — Dermoid, usually at the upper outer quadrant of the orbit, 
forms a hard, round tumor beneath the skin and unattached to it. It 
indents the bone, and at times projects through this structure into the 
orbit. When placed on the bridge of the nose dermoid grows downward 



THE EAR 253 

beneath the nasal bone^ displacing the cartilage. It is distinguished 
from sebaceous cyst by its deeper attachment, its position, and, when 
ulceration takes place, by the discharge of hair. Differential diagnosis 
cannot always be made. 

Echinococcus and cysticercus cysts (rare) developing on the face may 
be diagnosticated as such only by associated lesions or by excision. 

Cutaneous horns are recognized on sight. 

Adenomata .^ — Adenomata of the sweat and sebaceous glands occurring 
in old people cause nodular infiltration, particularly near the angle of 
the eye. These superficially ulcerating may resemble beginning epithe- 
lioma. Diagnosis can be made only by excision. 

Benign cystic epithelioma, usually appearing before puberty, form 
hard, indolent tumors, exhibiting little tendency to ulceration. The 
diagnosis is based upon the clinical course and microscopic examin- 
ation. 

Facial Neuralgia. — Facial neuralgia may be due to toxic conditions 
such as those incident to gout and rheumatism, may be a local expression 
of a general neuropathy, such as tabes, may be due to neuritis, or may 
be secondary to local causes such as carious teeth, otitis media, eye 
defects, inflammation of the maxillary or frontal sinus, or the pressure 
of growths. 

Trifacial neuralgia independent of these causes is epileptiform in 
its manifestations. It is nearly always unilateral, usually spares the 
first division of the nerve, though radiations of pain may take place 
to this, and is often accompanied by slight spasm of the muscles of 
the neck and face. The disease is characterized by recurring violent 
attacks of pain, sometimes preceded by an aura, often sudden in onset, 
accompanied by reddening of the skin of the affected side, perspiration, 
and hypersecretion of saliva and tears. Between the paroxysms, which 
may be brought on by eating, talking, touching of sensitive points, there 
are intervals of complete relief. The affection attacks by preference 
middle-aged men. The diagnosis is suggested by the severity of the 
symptoms and the persistent recurrence. Hysteria must be excluded and 
from the therapeutic standpoint the epileptiform attacks, which are 
cured only by formidable operations, must be distinguished from those 
due to a peripheral source of irritation. 



THE EAR. 

The meatus and drumhead of the ear are examined by means of a 
conical speculum, light being furnished by a head mirror provided 
with a central aperture. This examination is facilitated by drawing the 
pinna upward and outward, since thus the meatus is straightened. 
The drumhead lies at about the depth of one inch in the adult. 

The condition of the Eustachian tube as to its perviousness is deter- 
mined either by inflating through the nose while the patient is swallowing. 



254 THE HEAD, FACE, AND NECK 

or, more readily, though less accurately, by directing him to take a 
deep inspiration, close the mouth and nose with the hand, and endeavor 
to blow out through both at the same time. This, if the Eustachian 
tube be open, will cause a sense of fulness in the ears. 

Hearing can be roughly tested by the watch, the patient being directed 
to close his eyes during this test. If impaired, the question as to whether 
the deafness be due to abnormality in the conductive or the receptive 
apparatus may be determined by means of a tuning fork. If this, 
while vibrating, have its handle pressed firmly upon the forehead, it 
will be heard most distinctly in the ear in which the conductive apparatus 
is deficient. In the normal ear the tuning fork should be heard by air 
conduction after the bone conduction has ceased to convey impression. 

The symptoms of surgical affections of the ear are pain, alteration in 
the sense of hearing, and discharge, supplemented in the case of acute 
inflammation by the local and general symptoms of this condition. 

Malformations. — Congenital Deformities of the Auricle. — These are 
sufficiently obvious to inspection. The tragus may depart from the 
normal either in size or conformation. Rolling in of the helix and flaring 
of the pinna are perhaps the two commonest congenital deformities. 

Auricular appendages appearing as cartilaginous skin tabs are found 
on a line with the tragus and the angle of the mouth. The external ear 
may be entirely absent. 

Congenital fistula from which there is an oily crusting discharge 
has been observed in the lobe of the ear. 

Sebaceous cysts, angiomata, and fibromata are the usual benign tumors. 
Of the malignant ones, epithelioma is comparatively common as compared 
to sarcoma. 

Wounds of the Ear. — Contusion. — Subcutaneous blood effusions, 
sometimes without history of trauma, especially frequent among the 
insane, reach their greatest size on the posterior outer surface, from which 
they are rapidly absorbed. When they develop on the inner surface they 
are usually associated with lesion of the cartilage, and, if the ear be 
subjected to repeated trauma, result ultimately in a thickening which 
obliterates the normal folds. 

Wounds of the external auditory canal, if severe, are usually compli- 
cated with other more immediately urgent injuries. 

Fracture of the bony meatus is most likely to be caused by force applied 
to the chin, driving the condyle upward and backward, at times to such an 
extent that it entirely obliterates the canal The characteristic symp- 
toms are hemorrhage from the ear, pain located in front of the tragus 
and greatly aggravated by movement of the jaw, extreme tenderness at 
the same point, and subcutaneous blood effusion or actual break in the 
skin surface of the meatus, though the drum membrane is likely to be 
intact, nor is there interference with hearing. Trauma sufficient to 
cause this injury is usually associated with concussion of the brain and 
often with basilar fracture. 

Wounds of the Tympanic Membrane. — Wounds, if from direct violence, 
are often due to maladroit efforts at extraction of foreign bodies. Violent 



THE EAR 255 

air concussion may produce rupture of this membrane. It is some- 
times broken by insufflation, by a violent upward pull on the pinna, as 
the result of paroxysmal cough, or from excessive air pressure or the 
reverse. 

The ruptures from indirect violence are usually incident to fracture 
of the base of the brain; exceptionally, to blows on the head in 
the absence of fracture. The lesion is characterized by severe but 
transitory pain, and bleeding from the ear, at times very free. Dulness 
of hearing is, as a rule, but slightly marked. Direct examination shows 
the lesion, the lips of which are commonly closed by a small blood clot. 

Foreign Bodies. — Often found in children, they may occasion no 
symptoms excepting slight interference with hearing. As a reflex, per- 
sistent cough is frequently noted. As a rule, foreign bodies cause acute 
inflammation characterized by severe pain, swelling, and discharge 
of pus. Perforation of the drumhead and suppuration of the middle 
ear are likely to follow. Diagnosis is based upon direct examination. 

Concretions of cerumen in the ear are characterized simply bv deafness 
which comes on very slowly; at times with great rapidity. This is not 
infrequently associated with tinnitus and with headache and vertigo 
which closely simulate cerebral aft'ections. 

Acute Tympanic Congestion. — Acute tympanic congestion incident 
to exposure to cold, moderate trauma, or blocking of the Eustachian tube 
is characterized by an initial pain as severe as that which ushers in otitis 
media, and differs from the latter only in the fact that it shortly subsides 
under almost any treatment. It is common in children. 

Acute Inflammation of the Auditory Meatus.— Acute inflamma- 
tion of the auditory meatus may be circumscribed or diffuse. Furuncle 
usually begins with an itching sensation in the ear, followed by extreme 
pain, greatly aggravated by movement of the jaws. Usually the swelling 
is sufficient to entirely close the meatus, and deafness results. The 
affection is likely to be recurrent. Its diagnosis is based upon inspection. 
Diffuse inflammation of the auditory meatus is frequent in infants and 
a common accompaniment of cutting the teeth. It is often due to 
traumatism inflicted by ignorant nurses in their attempts to clean "the 
ear, supplemented by infection through vomited matter or sometimes 
through milk directly injected. It is at times a complication of the 
exanthemata. 

The characteristic symptoms are severe pain aggravated by move- 
ments of the jaw, great tenderness on touching the external ear, swelling 
obliterating the depression in front of the tragus, slight fever; deafness 
and tinnitus only when the meatus is swollen shut. The skin of the 
meatus is reddened and swollen and the tympanum is usually inflamed. 
The herpetic form is characterized by vesicles. In two or three days 
there is a moderate seropurulent discharge, sometimes only sufficient 
in quantity to cause crusting. 

According to the particular form of infection the duration of the attack 
will be short or long. Exceptionally the disease involves both the 
tympanum and the bony canal of the meatus. 



256 THE HEAD, FACE, AND NECK 

Distinction from furuncle is made by noting that the entire canal is 
swollen. The immunity of the middle ear can be determined only if 
the swelling be of such moderate degree as to allow the direct ex- 
amination of the drumhead. When complicated by osteoperiostitis the 
distinction from middle ear disease is possible only on operation. 

Chronic external otitis is usually a complication of chronic otitis 
media. There is often superficial caries of the bone, causing pain, 
swelling, and tenderness on deep pressure and the development of fun- 
gous granulations. Infection is sometimes conveyed to the temporo- 
maxillary articulation. Nor is extension to the brain uncommon. 

Tumors of the Ear. — Polyps have been observed in the external 
meatus. Many of the reported cases are, however, instances of exuber- 
ant granulations. 

Exostoses, commonest among men, may be single or multiple. They 
grow slowly, causing inconvenience only when they obliterate. Diagnosis 
is based upon the density of the tumor, its indolent course, the absence 
ulceration or infiltration. 

Inflammation of the Middle Ear. — Common in infancy and youth, 
is usually secondary to nasopharyngeal catarrh. It may be primitive 
in the tympanum incident to traumatism. It is a common sequel of 
influenza, typhoid fever, scarlet fever, measles, indeed of all the exan- 
themata. It may be catarrhal or frankly suppurative. In the latter 
case there is commonly inflammation of the surrounding bone. 

Acute otitis media is characterized by severe pain and tension referred 
to the ear, which is tender to pressure on the tragus; pronounced deaf- 
ness and tinnitus. These symptoms are aggravated by swallowing 
motions, coughing, or any change of air pressure in the nasopharynx. 
In the suppurative cases these symptoms become rapidly and progres- 
sively worse, the pain being unbearable in its intensity and referred 
to the whole side of the head. Constitutional symptoms of sepsis 
develop, together with those of meningeal irritation. 

The attack sometimes begins with headache, vomiting, vertigo, and 
symptoms strongly suggesting meningitis, which in these cases is doubt- 
less present. Facial palsy may develop early. The tympanic mem- 
brane, at first reddened, becomes dull and opaque, nor, excepting in the 
early congestive stage, can the handle of the malleus be seen. Because 
of the accumulation of inflammatory exudate the posterior part of the 
membrane is bulged outward. 

When suppuration takes place, there are tenderness and swelling in 
the mastoid region and about the external ear, the drumhead ruptures, 
and pus and blood are discharged from the meatus. This is followed 
by immediate subsidence of symptoms and usually by cure with restor- 
ation of hearing which may be complete. 

If pus is retained because of thickened, resisting tympanic membrane, 
acute osteomyelitis becomes a complicating factor with meningitis, 
sinusitis, thrombosis or brain abscess, profound sepsis, and pronounced 
swelling of the meatus and surrounding soft parts, most marked in the 
mastoid region. If death does not occur from sepsis and brain complica- 



THE EAR 



257 



tions, there will be fluctuation, abscess formation, and exposure of 
dead bone. 

Perforation of the tympanic membrane is rare in infants, nor can they 
intelligently voice their subjective symptoms; hence, when they present 
symptoms of sepsis and brain involvement, the ear should be carefully 
examined (Duplay). This rule should also hold good in case of 
children suffering from exanthemata, typhoid fever, and la grippe who 
exhibit marked symptoms of cerebral irritation. 



Fig. 97 



Fig. 98 





Front and rear view of external swelling in otitis media. (Aklerton.) 



Chronic Suppurative Otitis Media. — Chronic suppurative otitis media 
is characterized by constant or recurrent, offensive, often blood-stained 
discharge from the middle ear, which escapes through a defect in the 
drumhead. The affection is indolent, subject to occasional painful 
exacerbations, and may interfere very little with hearing. It is often an 
expression of necrosis, and then presents exuberant granulations and an 
especially stinking discharge. 

The diagnosis of middle ear disease is made by direct examination. 

Polypi. — Polypi of the tympanum are usually mucous in character, and 
may be evidenced by vertigo, syncope, vomiting, and various nervous 
manifestations. They are usually characterized by mucopurulent dis- 
charge and deafness. The diagnosis is made by direct examination. 

Cancer. — Cancer of the tympanum (rare) may be primary or secondary 
by invasion from neighboring tissues. 

Symptoms are those of cancer elsewhere, i. e., rapid progress and inva- 
sion of all tissues. 

Cholesteatomata. — Cholesteatomata form yellowish grains made up 
of partly dried pus, epithelium, fat, cholesterin crystals, and detritus. 
17 



258 THE HEAD, FACE, AND NECK 

Symptoms are those of a chronic suppurative middle ear disease. The 
diagnosis is based upon the finding of the yellowish masses which are 
stinking and suflSciently soft to crush between the fingers. 

Mastoiditis.— Mastoiditis, secondary to middle ear disease, is a common, 
often unrecognized, cause of high temperature and meningitis in infants. 
It is characterized by pain, swelling over the mastoid region, tenderness on 
tapping, and redness and infiltration of the posterior wall of the bony 
meatus, associated with constitutional symptoms of septic absorption. 

The complications of acute or chronic inflammation of the tympanum, 
antrum, or mastoid cells are meningitis, sinus thrombosis, brain abscess, 
and non-suppurating encephalitis. Infection is usually direct, even in 
case of apparently deeply placed brain abscess. 

These complications may develop in the course of an intercurrent acute 
attack of otitis, or in the absence of this, and long after discharge has 
entirely ceased. 

Acute encephalitis appears as a limited area of hemorrhagic softening, 
and leaves on recovery a sclerotic patch (Starr). It exhibits the symp- 
toms of cerebral abscess, nor can the differential diagnosis from this 
condition be made except by the progression of septic and pressure 
symptoms in the latter case. 

Cerebral abscess usually in the temporosphenoidal lobe or cerebellum 
(p. 236) is characterized by an initial period of severe constant or 
recurring headaches, mental lethargy, irregular temperature and pulse, 
followed shortly (days or weeks) by pressure symptoms, i. e., slow pulse, 
abnormal temperature (usually low), and late optic neuritis. If the 
temporosphenoidal lobe be involved, localizing symptoms may develop 
in the form of sensory or motor aphasia, cortical epilepsy, facial palsy. 

If the abscess is in the cerebellum, staggering gait and vertigo and 
vomiting may be leading symptoms. Death in coma may occur quite 
suddenly without any of these localizing symptoms. 

Meningitis is evidenced by its severe pain, rapidly progressive course, 
continued high temperature, rapid irregular pulse, general hyperesthesia, 
rigidity of the muscles of the back of the neck, and the presence of 
microorganisms and polymorphonuclear leukocytes in the cerebrospinal 
fluid obtained by lumbar puncture. 

Sinus thrombosis (exceptionally sterile) is characterized by the symp- 
toms of meningitis plus a more rapid and virulent systemic infection. 
The high temperature is subject to sudden and violent fluctuations with 
recurring chills. There is at times venous congestion of the side of the 
head, exophthalmos, and early development of choked disks. Extension 
into the neck is denoted by induration and tenderness along the jugular 
vein. 

The differential diagnosis of these complications, one from the other, 
is of no importance if acute encephalitis be excepted, since they all 
require operative treatment which is successful in proportion to its 
timeliness. 



THE EYE 259 



THE EYE. 



There are some skin lesions which exhibit a special predilection for 
the skin in the region of the eyelids. 

Herpes. — Herpes, an occasional expression of fever, is characterized 
by vesicular lesions which usually appear in the form of a cluster or a 
coalescent patch. Herpes zoster is a specific exanthem the painful 
vesicular lesions of which are grouped in irregularly shaped inflamed 
patches along the cutaneous distribution of the frontal or nasal nerve. 
The area supplied by the supra-orbital nerve is the one commonly 
affected. 

If the eruption involves the distribution of the nasal branch, conjunc- 
tival vesicles and corneal blebs, followed by ulceration and inflammation 
of the iris and ciliary body, are common accompaniments. 

Furuncle, or Stye.-y-Furuncle, or stye, a marginal boil, usually acute in 
onset, rapid in course, and prone to recur, originates in a sebaceous 
gland or hair follicle, usually near the free border of the dermal surface 
of the upper lid. 

The pre-auricular lymphatic gland is often enlarged. 

Acute Chalazion. — Acute chalazion presents much the appearance of a 
stye. It arises in a meibomian gland. 

Blepharitis. — Blepharitis or marginal inflammation of the eyelids may 
be non-ulcerative or ulcerative. 

Ciliary, or non-ulcerative, blepharitis, the commonest form is char- 
acterized by redness and slight thickening of the margins of the lids with 
the formation of scales and small crusts. It is a form of seborrhea of 
the lid margin and is often accompanied by seborrhea of the eyebrows 
and scalp. 

Ulcerative blepharitis is a special localization of eczema on the lid 
border. The discharge is more obvious than in the previous variety, the 
crusting more marked, and pustules and ulcers develop along the lid 
margins which in their cicatrization cause marked deformity. The 
eyelashes may be turned in or out or may be entirely shed. The external 
commissure is usually ulcerated, and cicatrices form here, while a similar 
condition about the internal commissure causes deviation of the lacry- 
mal points or even their entire obliteration, with consequent epiphora. 

Chancre. — Chancre forms an ulcerating, indurated surface which may 
manifest pronounced inflamraatory swelling. The rapid course (days or 
weeks), the induration, the presence of the specific microorganism, and 
the glandular adenopathy are characteristic (pre-auricular if the lesion 
involve the outer portion of the lower lid; submaxillary if elsewhere). 

Lupus. — Lupus attacks the lids by extension from neighboring parts, 
and appears in the form of reddish tubercles which usually terminate 
in ulceration and cicatrization. 

Milium. — ^The eyelids are especially the seat of minute cysts due to 
obstruction of the sebaceous glands, forming whitish grains at times so 
numerous as to occasion considerable disfigurement. 



280 THE HEAD, FACE, AND NECK 

Small translucent tumors from the sudoriferous glands are occasionally 
seen at the borders of the eyelids. 

Chalazion, a benign newgrowth occurring in connection with a mei- 
bomian gland, and commonly attended with retention of the secretion, 
forms a rounded, yellowish or red, semitranslucent, dense tumor, usually 
about the size of a pea, and closely adherent to the tarsal cartilage. 
The direction of growth may be inward or toward the skin. 

Xanthoma. — ^Xanthoma is characterized by the development, usually 
on the upper lids, of flat, slightly raised, non-indurated, non-inflammatory 
concentric patches of yellow discoloration. 

MoUuscum Contagiosum. — Molluscum contagiosum forms typical flat, 
rounded, split-pea sized, waxy elevations exhibiting a dark colored 
aperture from which curdy material can be expressed, and is associated 
with similar lesions elsewhere. 

Angioma. — Angiomata, particularly in the form of birthmarks, are fre- 
quent. 

Plexiform neuroma forms a disfiguring tumor, involving the skin and 
subcutaneous tissue, sometimes associated with diffuse lymphangioma 
and hemangioma. 

Papilloma. — Papilloma is fairly common on the lids. It may become 
pedunculated, or on an elderly person undergo epitheliomatous degenera- 
tion. 

Cutaneous horns have been observed. 

Epithelioma. — Epithelioma, fairly frequent, is observed most commonly 
at the inner portion of the lower lid after the fortieth year. Blepharitis 
is a predisposing factor. A wart or seborrheic patch is often the starting 
point. It begins as a small, superficial, persistent ulceration. It is slow 
(years) in progression and usually of the rodent ulcer type, ultimately 
destroying all the neighboring structure including the eyeball. The 
diagnosis should be made early by wide excision and microscopic 
examination. 

Sarcoma and Carcinoma. — Sarcoma and carcinoma of the lids (rare) 
conform to type in that they grow rapidly (weeks, months). Diagnosis 
should be made early by wide excision and microscopic examination. It 
would be suggested by exclusion of other causes for tumor formation 
and the absolute failure of less radical means of treatment. 

Epiphora .^ — Epiphora, or habitual overflow of tears upon the cheeks, may 
be due to deviation of the puncta lacrymalia incident to inflammatory 
swelling, cicatricial contracture, or paralysis of the orbicular muscle; 
to narrowing or closure of the puncta or canaliculi, by inflammation, 
polypoid growth, or tear stone, to dacryocystitis or inflammation of the 
lacrymal sac, or to stricture or obliteration of the lacrymal duct. 

Deviation or obstruction of the puncta or canaliculi can be detected 
by inspection and gentle probing. 

Dacryocystitis. — ^Dacryocystitis is characterized by a swelling just below 
the inner canthus of the eye from which pus or mucus can be pressed 
through the puncta lacrymalia. ' 

Acute inflammation is marked by pronounced swelling centring in 



THE EYE 261 

the position of the sac, but spreading widely and giving constitutional 
symptoms of septic absorption. 

Fistula may follow suppuration, much resembling the sinuses not 
infrequent near this position as the result of syphilitic or traumatic 
caries of the lacrymal bone. 

Stricture of the Nasal Duct. — Stricture of the nasal duct usually at its 
extremities is consequent upon a chronic catarrhal condition of the 
mucous membrane. It may be caused by nasal catarrh, necrosis of the 
bone, trauma, or the pressure of growing tumors. Its presence is deter- 
mined by the use of lacrymal bougies, or by injecting fluid through the 
canal with an Anel syringe. 

Affections of the Conjunctiva.— Hyperemia.— This affection, some- 
times called dry catarrh, since it is unaccompanied by discharge, is 
characterized by an injection chiefly of the bulbar vessels and some 
swelling of the conjunctival follicles. Its chief causes are eyestrain, 
exposure to local irritants (for example, dust and smoke), the abuse of 
alcohol, nasal catarrh, acute coryza, or hay fever. 

Sometimes an acute hyperemia is sudden in onset, and is associated 
with profuse lacrymation and a gritty sensation when the eyelids are 
moved. The presence of a foreign body is suggested, nor can this 
possibility be eluninated except as the result of careful examination, 
including eversion of the lid and inspection of the upper cul-de-sac. 

Certain stubborn hyperemias of the conjunctiva are of constitutional 
origin, and may be significant of gout and, in general terms, lithemia. 

Conjunctivitis. — ^This is a true inflammation of the conjunctiva, and is 
evidenced by redness and swelling of this membrane, increased and 
usually altered secretion, lacrymation, some photophobia, and burn- 
ing pain. Certain definite varieties of this disease require special 
mention : 

Simple, or Catarrhal Conjunctivitis. — In this affection there are con- 
gestion and loss of transparency of the tarsal conjunctiva, moderate dread 
of light, and a mucous and later mucopurulent discharge which slightly 
glues the lids. Such a conjunctivitis may be associated with eczema, 
nasal catarrh, bronchitis, and various fevers, or may be of mechanical 
origin from exposure to wind and dust, and is not specially contagious, 
nor are microorganisms of specific character found in its secretion, 
although the ordinary pus organisms, for example, staphylococci and 
streptococci, may be demonstrated. All ages of life are liable to catarrhal 
conjunctivitis, but it is more frequently observed in children and young 
persons. 

Acute Contagious Conjunctivitis. — There are several varieties of this 
disease which in its symptoms resembles an exaggerated catarrhal 
conjunctivitis. After an incubation period of about thirty-six hours a 
severe form of inflammation develops, with thick, stringy, mucopurulent 
discharge, swelling of the retrotarsal folds, and not infrequently small, 
subconjunctival hemorrhages. Occasionally the inflammation is suffi- 
ciently violent to produce a distinct chemosis of the conjunctiva. The 
acute stage lasts from four to ten days. The disease may occur at any 



262 THE HEAD, FACE, AND NECK 

age, is commonest in warm and changeable weather, and is markedly 
contagious. The active microorganism is the so-called Koch- Weeks 
bacillus. 

Another form, which in all clinical respects resembles the one just 
described, is due to the presence of the pneumococcus, and like the Koch- 
Weeks bacillus conjunctivitis, is intensely contagious, and may occur in 
epidemics. 

Another form is characterized by less marked inflammatory symptoms, 
the discharge is thinner and more copious, and the majority of the cases 
occur in young children, even in infants, in whom the affection is much 
more severe than in adults. The active microorganism is the influenza 
bacillus, which has many morphological characteristics resembling the 
Koch- Weeks bacillus. 

Diplobacillus conjunctivitis, due to the Morax-Axenfeld bacillus, 
usually runs a subacute, rather tedious course, especially characterized by 
soreness of the commissural angles. It may also appear in acute mani- 
festations with free discharge. It is quickly cured by lotions of sulphate 
of zinc which is practically a specific remedy in this affection. 

Diphtheritic Conjunctivitis. — Diphtheritic conjunctivitis, at least the 
deep-seated or necrotic variety of the disease, is characterized by a board- 
like, painful swelling of the lids, a scanty, seropurulent or sanious dis- 
charge, and exudation within the layers of the tarsal conjunctiva, which 
may spread to the ocular conjunctiva. It is commonest between the 
ages of two and eight. At one time chiefly seen in France and Northern 
Germany, in recent years it has become more frequent in America and 
in England. The Klebs-Loeffler bacillus is found in the secretion, 
and, unless the process is checked, there will be rapid sloughing of the 
cornea. 

Gonorrheal Conjunctivitis. — This may occur in babies and is usually 
known under the term ophthalmia neonatorum, the infection being 
derived during birth from the genital passages of the mother. In 
adults it is called gonorrheal ophthalmia, and is inoculated by fingers 
soiled by a gonococcal discharge. 

The disease is characterized by a rapid, acute course. An abundant 
secretion of thick, greenish pus rapidly supervenes, pronounced swelling 
of the conjunctiva appears, which in its ocular portion may overlap the 
cornea, and in its palpebral portion may project as a thick, edematous 
fold beneath the enormously swollen lids. The diagnosis can be 
promptly made by examining the secretion and finding the gonococcus 
of Neisser. 

All forms of acute purulent conjunctivitis may be complicated by 
corneal ulceration. This is uncommon in acute contagious conjunc- 
tivitis, but is exceedingly likely to occur in diphtheritic or gonococcic 
inflammation. 

From the therapeutic and prognostic point of view an early determin- 
ation of the cause of the acute conjunctivitis is of major importance. 
This can be made only by microscopic and bacteriological examin- 
ation of the secretion and the detection of the microorganism which 



THE EYE 263 

is active, though a history of exposure to diphtheria or gonorrhea will 
be suggestive. 

Many forms of purulent conjunctivitis, also in newborn infants, 
are due to microorganisms other than the Neisser coccus, for example, 
the pneumococcus, the Koch- Weeks bacillus, the bacterium coli, etc., 
and are not so serious in their prognostic import. 

Phlyctenular Conjunctivitis. — This is characterized by pinhead-sized 
yellowish or dirty white spots on the ocular conjunctiva, each form- 
ing the apex of a triangle of dilated bloodvessels radiating from this point 
to the conjunctival cul-de-sac. These points may suppurate or become 
implanted on the cornea and develop into corneal ulcerations. The 
symptoms are aggravated when the phlyctenulse are multiple, or are 
complicated by corneal ulceration. They are probably a manifestation 
of tuberculous infection. 

Granular conjunctivitis, or trachoma, is a contagious affection among 
those poorly nourished and closely crowded. It is commonest among the 
Russian and Polish Jews and the Italians. Children under ten years 
old are less liable to the disease than adults. 

Trachoma is evidenced by slight swelling and ptosis of the upper 
lid which on eversion exhibits small red or yellowish, semitranslucent, 
fleshy elevations which have been compared to grains of tapioca. There 
is ultimately always an associated conjunctivitis followed by cicatricial 
deformity of the lids, and vascularization (pannus) and ulceration of the 
cornea. 

Follicular conjunctivitis due to lymphoid overgrowth of the follicles 
appears in the form of a catarrhal conjunctivitis of moderate severity 
associated with a linear arrangement of minute semitranslucent, light 
red grains in the conjunctiva of the lower lid which externally is red- 
dened and swollen. 

It differs from trachoma in that it causes neither cicatrices of the lid 
nor corneal vascularization nor ulceration. 

Xerosis, or preternatural dryness of the conjunctiva, one of the sequels 
of neglected trachoma, is obvious on inspection. 

Chancre has been observed primarily on the conjunctiva. Lipoma 
or angioma, polyps, small cysts movable with the conjunctiva, and 
dermoids have been noted. 

Epithelioma and sarcoma are usually secondary. 

Affections of the Orbit. — Contusions. — Contusion of the orbital 
margin is characterized by abundant subcutaneous blood effusion 
which may swell the lids shut in a few minutes. The vulnerating force 
may cause fracture which makes a direct communication between the 
orbit and the nose or its sinuses. The resultant hemorrhage may be 
expressed in the form of bleeding, subconjunctival hemorrhage, chemosis, 
and, if extensive, exophthalmos. Crackling on pressure is indicative of 
communication with the nasal cavities. 

Fracture. — Fracture of the orbital brim may be detected by palpation, 
gentle massage enabling the surgeon to reach the bone even through a 
considerable blood effusion. 



264 THE HEAD, FACE, AND NECK 

Fracture of the roof of the orbit, usually caused by violence applied to 
the forepart of the vault of the skull, in addition to the brain symptoms 
consequent upon trauma sufficiently severe to cause this injury, may be 
characterized by subconjunctival hemorrhage and at times blindness, 
since the optic foramen and consequently the optic nerve may be involved 
in this fracture. 

Inflammation. — Acute inflammation of the cellulo-fatty tissue of the 
orbit, characterized by chemosis of the conjunctiva, exophthalmos, red, 
swollen, projecting lids, and pronounced constitutional symptoms of 
infection is usually secondary to inflammation of neighboring parts. 
Accessory sinus empyema, and the orbital thrombosis or lymphatic 
extension from carbuncle, boil, or erysipelas of the face are the com- 
mon causes. The orbital cellulitis may be secondary to contusion 
with fracture into the sinuses, to direct wound, or to systemic infection 
(scarlet fever, typhoid, influenza, erysipelas). The most common cause 
is infection from the accessory nasal sinuses. 

The diagnosis suggested by the symptoms given and usually by a 
preceding adjacent infection, and is corroborated by incision. 

In the virulent forms of orbital cellulitis secondary to facial erysipelas 
or carbuncle, or to the extension of septic thrombosis from the cavernous 
sinus, death usually occurs before free pus formation. 

Edema, chemosis, and exophthalmos incident to blood effusion or 
non-infected cavernous sinus thrombosis would not be attended by 
septic symptoms. 

Tumors of the Orbit. — The diagnosis of tumor of the orbit is usually 
based upon a visible, palpable, circumscribed, non-inflammatory swelling, 
which in the case of vascular tumors varies in size and consistency in 
accordance with vascular tension and which may pulsate. 

The benign tumor grows slowly, the malignant rapidly. When the 
diagnosis between these is doubtful it should be made by excision and 
microscopic examination. 

Osteomata or exostoses appear as bony outgrowths from the orbital 
walls, often from the frontal sinus, and are characterized by slow growth, 
density of structure, and displacement of the eyeball. The ic-ray picture 
is diagnostic. 

When too deeply placed to be seen or felt, the symptoms which may 
suggest diagnosis are pain, displacement of the eyeball, interference with 
the action of the extrinsic eye muscles, and venous congestion of the 
eyelids and surrounding skin. 

Tumors which arise from the orbital contents include hemangioma, 
lymphangioma, lipoma, fibroma, lymphoma, neuroma, simple and plexi- 
form, and sarcoma, with which should be included endothelioma. 

Simple angioma usually starts from a nevus of the lids extending 
inward. Sometimes it follows trauma. It forms a soft, pendulous, 
usually harmless mass in the upper part of the orbit, the tension of which 
is increased by straining efforts. 

Cavernous angioma, of slow development, causes exophthalmos 
markedly increased by straining efforts. This, together with its ill- 



THE EYE 265 

defined outline, its apparent reducibility, and its change in size incident 
to vascular tension, is characteristic. Varices are described, particularly 
in the upper inner portion of the orbit. 

Pulsatile tumor of the orbit, or pulsating exophthalmos, usually 
traumatic in origin, incident to basal fracture, is characterized by tin- 
nitus, followed by venous congestion about the lids, bruit, pulsation, 
exophthalmos, usually unilateral, and chemosis. The usual cause is an 
arteriovenous aneurysm (internal carotid and cavernous sinus). 

Palpation may reveal a tumor in the upper inner portion of the orbit 
made up of dilated vessels in which thrill can be distinctly felt. Vision 
is not always interfered with, though there is commonly palsy of the 
extrinsic muscles, particularly the external recti. In many cases, however, 
there are retinal hemorrhages and often neuritis and optic nerve atrophy. 

Plexiform neuroma (rare) is a congenital tumor associated with a 
similar growth in the surrounding skin. 

The lymphoma (Hochheim) may be simple, pseudoleukemic, or of 
doubtful nature. Leukemic tumors in both orbits occasionally appear 
in the form of multiple nodules associated with the symptoms of general 
leukemia. 

Growths that have been called tuberculous are really extensions into 
the orbit from a tuberculous periostitis often at the orbital margin where 
an induration forms which softens and discharges a purulent material 
unassociated with inflammatory signs. 

Sarcoma of the orbit, rare as a primary tumor and usually observed 
in young persons, may appear as spindle-cell, round-cell, or angiosar- 
coma, or most exceptionally as melanosarcoma. The growth develops 
rapidly (weeks or months), at times following trauma, and sometimes 
projects externally beneath the conjunctiva as a soft, elastic, lobulated 
tumor, which, depending upon its structure, may pulsate and appa- 
rently fluctuate. Osteosarcomata may develop slowly (months, years). 
Metastasis occurs early in the small round-cell growths, taking place 
through the blood stream ; at a later period in the fibrosarcomata. True 
endotheliomata, often classified with the sarcomata, have only a local 
malignancy. 

Primary sarcomata must not be confounded with those which appear 
in the orbit as extensions from the neighboring sinuses and from the 
choroid after rupture of the sclera. Under the last-named circum- 
stances the growth is almost invariably pigmented. 

Carcinoma grows from the lacrymal gland and closely resembles 
sarcoma in its development. 

The diagnosis of malignant orbital tumors should be made by excision 
and microscopic examination of all tumors not obviously benign. 

Cysts of the orbit are congenital or acquired. The congenital cysts 
include dermoids, teratoid cysts, inclusion cysts, meningoceles, and 
encephaloceles. 

Teratoma (rare) appears obviously at birth associated with marked 
deformity of the eye. 

Encephalocele and meningocele, common at the upper inner angle 



266 THE HEAD, FACE, AND NECK 

of the orbit and the position of the lacrymonasal canal, are present at 
birth, and exhibit an underlying bony defect, though this cannot always 
be felt. Characteristic symptoms are usually absent, and the tumor 
may readily be confounded with lacrymal hydrops or cold abscess of 
the bone. Reducibility and changes in tension incident to straining 
efforts would be diagnostic if present. 

Dermoids, the commonest form of orbital cyst, are commonly placed 
in the upper outer angle of the orbit. They are indolent, rounded tumors, 
usually not detected until about the age of puberty, when they begin to 
grow. They produce trouble only by mechanically displacing the tissues 
of the orbit. 

The acquired cysts include implantation cysts derived from the 
conjunctiva, and serous cysts, which are of obscure etiology and may 
possibly arise in connection with the sheaths of the extrinsic muscles in 
the form of bursse. Serous cysts may also be derived from hemorrhage 
in the orbit after degeneration of a blood clot. Extravasated blood in 
the retrobulbar tissue may become encapsulated and simulate a blood 
cyst. 

Inflammatory Affections of the Cornea. — The cardinal symptoms 
of these affections are corneal opacity, usually associated with a peri- 
corneal ring of injected bloodvessels, pain, photophobia, blepharospasm, 
hypersecretion of tears, and obscured vision. 

Foreign Body. — Foreign body embedded in the cornea causes first the 
symptoms of hyperemic conjunctivitis with severe pain on motion of the 
lids, usually referred to the position of the superior cul-de-sac. Corneal 
ulcer with its characteristic symptoms develops later. 

The detection of a minute body is accomplished by obliquely illumi- 
nating the cornea from the side by focussing light upon it through a lens 
while the observer inspects from in front through a hand magnifying 
glass; or by dropping upon the cornea a solution of fluorescein (2 per cent.) 
which colors green the abraded cornea and surrounds the dark foreign 
body by a green colored area. 

Phlyctenular keratitis, common in strumous, catarrhal children who 
are convalescent from an exanthem, is characterized by the formation of 
minute disseminated vesicles or pustules in the outer corneal surface 
resulting in superficial ulcers. The deeper forms leave scars. Photo- 
phobia is intense, relapses are frequent. Eczema of the nares and scalp 
and the lesions and symptoms of an infective rhinitis are commonly 
present. 

Ulcerations. — Ulcerations, superficial or deep, acute or chronic, cen- 
trally or laterally placed, may perforate the cornea, or, if they be acutely 
infected or sloughing (pneumococcus), may be complicated by pus in the 
anterior chamber. The ulceration occurs in those vitally depressed and 
as a result of traumatism or acute inflammation (conjunctivitis). 

Neuropathic ulceration, characterized by central necrosis and perfor- 
tion, is secondary to direct irritation of an eye which has lost its sensi- 
bility and is no longer protected by the lids, because of blocked innerva- 
tion (trigeminal). It is a common sequel of Gasserian ganglion removal. 



THE EYE 267 

Vascular Keratitis. — Vascular keratitis is secondary to trachoma and 
recurrent phlyctenular keratitis. Over the clear corneal window there 
sweeps from above and below (weeks or months) a veil of fine blood- 
vessels preceded by a fringe of opacity. 

Interstitial Keratitis. — This is usually due to hereditary syphilis, not 
infrequently to tuberculosis, and is characterized by corneal opacity due 
to a central infiltration, resembling ground glass. There is always pro- 
nounced vascularization, forming reddish patches, which may invade 
the entire cornea. Ulceration is rare. 

Inflammatory Affections of the Iris. — Iritis. — Iritis is character- 
ized by change in color and blurring of striation, a circumcorneal zone 
of congestion, contracted pupil reacting sluggishly or not at all to mydri- 
atics, with adhesions to the capsule of the lens (posterior synechium), 
haziness of the cornea, impaired vision, severe pain in the eye, temple, 
and forehead, tenderness of the eyeball, and photophobia. 

Plastic iritis, the usual form of the disease, is common in the first year 
of acquired syphilis. As an expression of rheumatism, gout, or gon- 
orrhea, it is recurrent in type. 

Uveitis. — Serous iritis is characterized by a pupil of normal size or, in 
its early stage, by one even moderately dilated, absence of early adhe- 
sions to the lens, haziness of the aqueous humor and cornea, with the 
deposit on the inner surface of this structure of dirty gray points grouped 
in triangular form with apices down. The anterior chamber is deepened. 
It occurs in late syphilis and in other infectious diseases, and may be a 
manifestation of intestinal autointoxication. A large percentage of the 
cases are due to tuberculous infection. 

Acute Glaucoma. — Acute glaucoma, an affection of middle and old age, 
is characterized by increased hardness of the eyeball, swelling of the 
conjunctiva and eyelid, anesthetic and hazy cornea, clouded aqueous 
humor, fixed discolored iris with partly dilated pupil, rapid loss of vision, 
and intense headache. The attack may be preceded by a rapid failure 
in accommodation for near objects characterized by a frequent change of 
glasses, recurring periods of failing vision, and the perception of spectral 
halos about artificial light. It should be distinguished from iritis by 
the absence of synechise, the semidilated pupil, and by the marked 
elevation of intra-ocular tension. 

Sympathetic Inflammation. — Sympathetic inflammation of one eye 
secondary to traumatic or perforating lesions involving the ciliary body 
of the other, usually develops within the first six weeks of the original 
lesion, and is characterized by the symptoms of iridocyclitis. A tender 
spot on the ciliary region may precede obvious symptoms. 

Sympathetic irritation is characterized by photophobia, failure of 
accommodation, and tenderness of the sympathizing eye, and is 
promptly relieved by removal of the exciting eye. It may be regarded 
as a neurosis or else as an early stage of the infective uveitis just 
described, which it sometimes precedes. 

Contusion of the Eye. — Sudden force applied to the eye may cause 
a flashing sensation followed by dilatation of the pupil, obscuration of 



268 THE HEAD, FACE, AND NECK 

vision, or even temporary loss ofsight; this in the absence of demonstrable 
lesion. The diagnosis is based upon the transitory nature of the symptoms 
and the exclusion of intra-ocular lesions by ophthalmoscopic examina- 
tion. 

Severe contusion usually causes hemorrhage into the anterior chamber, 
obscuring deeper lesions, the commonest of which are dislocation of the 
lens, detachment of the ciliary margin of the iris, and blood effusion 
between the retina and the choroid. 

Rupture of the sclera is characterized by prolapse of the choroid, or 
escape of the vitreous into the subconjunctival space where it may appear 
as a yellow-green jelly. There is usually abundant subconjunctival 
hemorrhage. 

Foreign Body. — Foreign body in the eye is characterized by a 
wound of entrance and intra-ocular bleeding. When the latter is marked, 
the presence and position of the foreign body must be determined by the 
x-rays, provided it is of such nature that it will cast a shadow on the 
plate, i. e., if it is iron or steel. Its presence may also be determined by 
the use of a large magnet, with which it is drawn either into the anterior 
chamber, through the wound of entrance, or through a scleral incision 
placed according to the findings of the rr-ray plate. 

Paralysis of the External Ocular Muscles of the Eye. — ^Paralysis 
of an ocular muscle may be caused by an intracranial or an orbital lesion. 
The intracranial lesion may be cortical, nuclear, fascicular, or basal in 
situation. The palsies of basal or orbital origin are due to inflamma- 
tory lesions, tumors, aneurysm, hemorrhage, or fracture. 

Syphilis is the most frequent cause of extra-ocular muscle palsy, and 
is the potent factor in about one-half of the cases. Other causes 
which may occasion nuclear or peripheral lesions are rheumatism, gout, 
diabetes, whooping cough, influenza, herpes zoster, and certain toxic 
agents, for example, lead, alcohol, gelsemium, carbonic acid and various 
ptomains. 

A paralysis of the external ocular muscles is seen in connection with 
locomotor ataxia, paretic dementia, disseminated sclerosis, and bulbar 
paralysis. 

Tabetic paralysis is often transitory in nature, but prone to relapse, 
and is usually associated with the pupillary changes and motor and 
sensory symptoms characteristic of this affection. 

Paralyses of the orbital muscles of cerebral origin may result from 
degenerative, hemorrhagic, or neoplastic lesions affecting the cortex 
of the brain, the corticopeduncular region, the nuclei of the nerves, or 
the nuclear fibers. 

Palsy of traumatic origin may be immediate and complete incident to 
direct injury, or to lesion consequent upon basal fracture or to pressure 
due to hemorrhage. A rapidly (days) developing palsy following 
injury may be due to traumatic reaction; or, should it come on more 
slowly (weeks), to formative periostitis. 

A number of cases of congenital paralysis are on record, and occa- 
sionally congenital syphilis is an etiological factor. 



THE EYE 269 

Paralysis of the abducens supplying the external rectus is most fre- 
quently encountered; next in order of frequency is unilateral paralysis 
of the oculomotor. After these come in order paralyses of the superior 
oblique, inferior rectus, superior rectus, internal rectus, and inferior 
oblique. 

The general symptoms common to paralysis of the external ocular 
muscles are the following: 

1. Loss of binocular single vision, or diplopia; always most manifest 
in that portion of the field to which the affected muscle normally rotates 
the eyeball. 

2. Strabismus, quite evident if the paralysis is complete, demonstrable, 
at times, only when the eye is turned toward the affected side, due to the 
unresisted action of the antagonist of the paralyzed muscle. 

3. Limitation of that movement which is given to the eye by the 
affected muscle. The deviation of the eye is always in a direction 
opposite to the action of the muscle. 

4. False projection of the field of vision. This depends upon an in- 
accurate estimation of the position of an object situated in such a portion 
of the visual field that it requires an effort on the part of the affected 
muscle to turn the eye toward it. For example, if a patient with a paretic 
left external rectus is required to touch an object to the left of the point 
of fixation, he will pass his hand beyond it, that is, to the left of it. Other 
marked symptoms are vertigo and an altered position of the carriage of 
the head, which is placed in such a position as to give the patient the 
least trouble with his double images. 

If there is complete paralysis, a diagnosis is easily made by remember- 
ing the dominant action of each ocular muscle, namely, that the external 
muscle rotates the eye outward, the internal rectus inward, the superior 
rectus upward, and the inferior rectus downward, while the superior 
oblique has for its muscular actions intorsion, that is, it rotates the 
vertical meridian inward and also lowers and abducts the eye, while 
the inferior oblique produces extorsion, that is, it rotates the vertical 
meridian outward and also elevates the eye and abducts it. 

Single ocular muscle palsies are often so incomplete that the defects 
in the rotations of the eyeball are not appreciable on inspection. The 
affected muscle must then be determined by applying the law of 
diplopia. 

The patient seated with the head and eyes in the primary position, 
about 4 meters from a test object, for example, a candle flame, has one 
eye covered with a piece of red glass. If diplopia is developed, one image 
will be yellow and the other red. The lighted candle is then moved 
from the median line to the right, to the left, upward, downward, and 
in oblique positions. Double images are chiefly seen when the eyes are 
turned in the direction requiring an action of the affected muscle. The 
image of the affected eye, that is, the false image, is projected in a direc- 
tion toward which the paralyzed muscle normally rotates the eye. When 
the test object is moved in the direction of the paralyzed muscle, the 
distance between the double images increases. 



270 THE HEAD, FACE, AND NECK 

There are two varieties of diplopia, according to the relation which the 
double images bears to the eyes. If the right image pertains to the right 
eye and the left image to the left eye, the diplopia is homonymous; if 
the right image pertains to the left eye and the left image to the right 
eye, the diplopia is crossed. If the images are side by side, that is to 
say, there is lateral diplopia, either the external or the internal rectus 
is affected. If the diplopia is homonymous and is most marked when 
the test object is carried into the right field, the right external rectus 
is affected. If the diplopia is crossed, there is paralysis of an internal 
rectus, the internal rectus of the left eye if the images separate to the 
right, and the internal rectus of the right eye if the images separate to 
the left. 

Vertical diplopia in the upper field indicates paralysis of the superior 
rectus, or the inferior oblique; if the vertical diplopia is chiefly noticed 
in the lower field, there is indication of paralysis of the inferior rectus or 
the superior oblique. If the diplopia is homonymous and vertical in the 
upper field, there is probably paralysis of an inferior oblique, the right if 
the image of the right eye is higher, the left if the image of the right eye 
is lower. If the diplopia is crossed and vertical in the upper field only, 
there is probably paralysis of a superior rectus, the right superior rectus 
if the image of the right eye is higher, the left superior rectus if the 
image of the right eye is lower. If there is vertical diplopia chiefly in 
the lower field and it is homonymous, there is probably paralysis of a 
superior oblique, the right superior oblique if the image of the right eye 
is lower, the left superior oblique if the image of the right eye is higher. 
If the diplopia is crossed and vertical in the lower field only, there is 
probably paralysis of an inferior rectus, the right inferior rectus if the 
image of the right eye is lower, the left inferior rectus if the image 
of the right eye is higher. 

A certain number of ocular paralyses are associated, that is to say, the 
eyes cannot make certain movements in which they are usually associated, 
although the directing power of the muscles may be uninjured when they 
exercise their function in a different association. For example, the 
internal recti may be unable to draw the eyes together in the act of 
convergence, although they may act normally in helping to move the eyes 
from side to side. These are the conjugate lateral paralyses, and depend 
upon lesions affectmg the centres of combined movement, or upon sym- 
metrical disease of the nuclei of the affected nerves. 

Sometimes, for example, in apoplexy the head is drawn from the 
paralyzed side and the eyes are also turned to the sound side, that is, 
there is conjugate deviation of the head and eyes. In lesions of the hemi- 
sphere the eyes are turned toward the lesion and away from the paralyzed 
side, but in lesions of the mesencephalon they are turned away from the 
lesion and toward the paralyzed side. 

When there is complete paralysis of all the muscles of the eye, the 
term ophthalmoplegia is applied, that is to say, there is ptosis and com- 
plete immobility of the eyeball. Such conditions may depend upon 
diseases of the nuclei, for example, a hemorrhagic polioencephalitis, 



THE NOSE 271 

tuberculosis, syphilis, ptomain poisoning, acute poliomyelitis, bulbar 
palsy, etc. 

If only the branches of the oculomotor are affected, either peripherally 
or centrally, there is ptosis and complete immobility of the eyeball except 
in so far as the movements of the external rectus, which is supplied by the 
abducens, and the superior oblique, which is supplied by the fourth nerve, 
are concerned; outward movement and intorsion, that is to say, wheel 
movement inward, are preserved. 

Paralysis of the ophthalmic division of the fifth nerve causes anesthesia 
of the conjunctiva and cornea and strongly predisposes the latter tissue 
to ulceration. It has often been noted after excision of the Gasserian 
ganglion. 

Paralysis of the sympathetic in the neck causes contraction of the 
pupil, slight sinking inward of the eyeball, and is sometimes a symptom 
of cervical fractures, tumors, and aneurysm. 

The practitioner should be able to make a differential diagnosis be- 
tween a concomitant squint, one in w^hich the squinting eye follows in 
all particulars the movements of the non-squinting eye, and a paralytic 
squint, one in which the rotation in the line of direction of the action of 
the affected muscle is limited. The common crossed eye of childhood 
which depends upon the presence of refractive error, usually hyper- 
metropia, amblyopia of one eye, and failure of proper development of the 
fusion sense, is readily differentiated from a strabismus caused by paralysis 
of the external rectus by noting that in the paralysis the outward move- 
ment of the eye would be lost or diminished, while in the concomitant 
strabismus it is unimpaired. Diplopia in association with concomitant 
strabismus is unusual. If sought for it is always found in the various 
types of paretic or paralytic strabismus. 



THE NOSE. 

The nose forms the channel for normal respiration, contains the 
organs of smell, is an important adjunct to the sense of taste, and imparts 
resonance to the voice. The symptoms of its disease are deformity, 
anterior or posterior discharge, nasal obstruction, attested, if bilateral, 
by mouth breathing and nasal speech, and loss or diminution of the sense 
of smell. Because of the great vascularity bleeding is common. 

Chronic mucous or mucopurulent discharge is symptomatic of 
hypertrophic or atrophic rhinitis, or of catarrh secondary to obstruction 
from polyps, tumors, deviated septum or non-ulcerating, syphilitic in- 
filtration. Chronic, frankly purulent, abundant discharge is usually 
due to sinus empyema, dead bone, or foreign body. 

Free hemorrhage (epistaxis) is usually traumatic. If slight but 
dangerously persistent, is hemophilic. It is symptomatic of Bright's 
disease, cirrhosis, cardiopathies, gout, typhoid, indeed, all eruptive 
fevers. It is common in children, and is in them usually due to a slight 
underlying mucous membrane lesion. It is at times menstrual. Excep- 



272 THE HEAD, FACE, AND NECK 

tionally, it is associated with intranasal angioma. Free serous dis- 
charge is observed in the early stage of acute coryza; if continuous and 
not associated with inflammatory symptoms, it is cerebrospinal fluid 
(fracture of the base, hydrocephalus). 

Examination of the nasal cavities is conducted by means of a head- 
light, a dilating speculum, and long-handled rhinoscopic mirrors. It 
is preceded by swabbing the nasal mucous membrane, the base of the 
tongue, both surfaces of the soft palate, and the nasopharynx with a 
10 per cent, solution of eucaine lactate, containing adrenalin chloride 
1 to 10,000. 

Digital examination of the nasopharynx is serviceable when the mirrors 
cannot be used. 

Congenital Deformities. — ^The nose may be double or bifid. The 
nostrils may be narrowed or occluded, in the latter case usually far back, 
by a diaphragm. 

Acquired deformities incident to traumatism or inflammation (usually 
syphilitic) are characterized by lateral deviation, or sinking in of the 
bony or cartilaginous framework, or both, or occlusion of the nostrils by 
septal overgrowth or adhesions between the septum and the turbinates. 

Traumatisms. — Contusion. — This is characterized by free bleeding from 
the nostrils, usually moderate, subcutaneous blood effusion, and swell- 
ing. There may be found a septal hematoma forming a dark, rounded, 
soft projection partially or completely obstructing the nostril. When 
these blood bosses are found on both sides of the septum, and particularly 
when there is intercommunication between them, fracture is present. 

Fracture. — Fracture of the nose is usually found in the lower third of 
the nasal bones and the cartilaginous septum. The nasal process of the 
superior maxillary, the lacrymal, the sphenoid, or the ethmoid may be 
involved. These fractures are often comminuted, and, because of the 
closely applied mucous membrane, there is free epistaxis, often subcu- 
taneous emphysema which may appear in the orbit and produce exoph- 
thalmos. In the absence of great swelling, deformity and crepitus are 
elicited without difficulty. 

The septum should always be examined, since a break in its cartilagi- 
nous portion or disjunction of this portion from its union with the vomer 
is common. In either case, if there be overlapping, the nose will be 
sunken, deviated, and preternaturally mobile. Bilateral septal bosses 
are characteristic, and, by means of a probe or the finger, deformity can 
be felt and corrected. 

Force sufficient to fracture the base of the nasal bone is usually com- 
plicated by a basal fracture and brain symptoms. It is also likely to 
involve the perpendicular plate of the ethmoid. 

Affections of the Nasal Orifice and Vestibule. — Erysipelas. — 
Erysipelas has its common point of departure from about the nose (see 

Furuncle. — Furuncle commonly placed just within the nasal orifice, 
often recurring, is characterized by the severe pain which it causes in this 
position. 



THE NOSE 273 

Acute erythema and eczema are common accompaniments of nasal 
catarrh. 

Acne Rosacea. — ^The thick, vascular, closely adherent skin overlying 
the alae and tip of the nose is peculiarly subject to acne and vascular 
dilatation, producing a red, nodular overgrowth common in habitual 
drinkers but not confined to them. 

Ulcerations. — Ulcerations are syphilitic, tuberculous, or malignant. 
Chancre may begin on the skin surface or just within the nostril; in 
the latter case incident to infection carried by the finger. The apparent 
causelessness, the rapid growth (weeks), the induration, the subjective 
symptoms, and particularly the characteristic adenopathy, should at 
least suggest a diagnosis. A septal chancre is usually not suspected until 
secondary eruptions develop. 

Tuberculous ulceration in the form of lupus has already been described 
(p. 247). 

Malignant ulceration, common about the nose of the elderly, begins 
as an indolent, persistent, scabbing, superficial ulcer, the true nature of 
which can be detected at a serviceable time only by excision and 
examination. 

Elephantiasis. — Elephantiasis exhibits a predilection for the nose, pro- 
ducing hideous disfigurement. 

Affections of the Mucous Membrane Characterized by the Rapid 
Onset (Hours or Days) of Inflammatory Symptoms. — Acute Rhinitis 
(Coryza). — Commonly attributed to exposure to cold, it is usually 
an expression of a toxemic condition (measles, typhoid, etc.), or of a 
reaction against an irritant, such as pollen (rose cold, etc.), or bacteria. 

It is characterized by heat, redness and swelling of the mucous mem- 
branes of the nasal cavities, accompanied by first serous then muco- 
purulent dischage. The sw^elling obstructs nasal breathing, lessens or 
entirely suspends the sense of smell, and diminishes the acuteness of 
the sense of taste. Tinnitus and dulled hearing are the expressions of 
an accompanying nasopharyngeal catarrh. Involvement of the frontal 
sinus is evidenced by dull frontal headache, which becomes extremely 
severe if the infundibulum be blocked, and is then subject to sudden 
remissions often preceded by a ' bubbling sound. This infection, if 
grippal, commonly extends to all the nasal mucous surfaces and down- 
ward to the lungs, and is accompanied by the general pains and fever of 
septic toxemia. 

Diphtheritic rhinitis is characterized by the severity of both the local 
and constitutional symptoms and the finding of the bacillus. This 
infection may occur in the absence of throat involvement, and may 
assume a chronic form with persistent toxemia as its most pronounced 
manifestation. 

Foreign Bodies and Nasal Calculi. — Foreign bodies are characterized 
by obstruction of one fossa and a unilateral, purulent, blood-streaked 
discharge often associated with recurring slight attacks of epistaxis. 
It is commonest in children. Diagnosis, suggested by discharge from 
one nostril, is confirmed by careful examination. A foreign body, if 
18 



274 THE HEAD, FACE, AND NECK 

not removed, may lie embedded in a mass of granulation tissue closely 
resembling cancer. 

Maggots have been observed in the nasal fossa. 

Nasoliths cause the symptoms of foreign body — ^with, however, a 
more gradual onset. 

Affections Characterized by Chronic Nasal Discharge. — ^All 
obstructive lesions are accompanied by chronic rhinitis, including 
under this heading septal deflections or overgrowths, foreign bodies, 
diseases of the accessory sinuses, and syphilitic or tuberculous infiltration 
and ulceration. 

Chronic Rhinitis. — Chronic rhinitis may be hypertrophic or atrophic. 

Hypertrophic rhinitis is characterized by mucopurulent discharge 
and nasal obstruction aggravated by slight causes. Examination shows 
a vascular, freely secreting, sometimes crusted, mucous membrane, so 
thickened as to fill the nasal cavity. The turbinals are often edema- 
tous, suggesting the appearance of a sessile polyp. 

Atrophic rhinitis, common in the female, and to an extent hereditary, 
is characterized by a sweetish, sickening stench appalling to every- 
one but the patient. The nasal fossae are unduly roomy, and to the 
atrophied mucous membrane adhere foul crusts which come away 
reluctantly, leaving eroded mucous membrane. Syphilitic, neoplastic, 
and foreign body rhinitis may all give an offensive odor, but resemble 
atrophic rhinitis in no other respect. 

Tertiary Syphilis. — ^Tertiary syphilis in the form of gummatous infiltra- 
tion may rapidly destroy both the bones and cartilages of the nose. The 
intranasal affection begins insidiously and painlessly. It is usually symp- 
tomless until it reaches the ulcerating stage, where it is characterized 
by a discharge which is peculiarly offensive, often streaked with blood 
and shortly contains fragments of bone or cartilage. 

Diagnosis is based upon profuse offensive discharge, direct examina- 
tion which either to the eye or to the probe may evidence the existence 
of exposed bone or cartilage, and the history of preceding syphilis 
with the associated signs of this affection. Deformity produced by 
ulcerating gumma is highly characteristic, nor is there any other affec- 
tion which can cause this in the same insidious manner. 

Gummatous infiltration of the cartilaginous septum is the usual cause 
of perforation. This result may also follow abscess or simple ulcer due 
to the habit of picking the nose. 

Perforations of the palate are usually due to the gumma beginning 
on the nasal aspect of this bone, and not appearing as a swelling on the 
roof of the mouth until the bone has been destroyed. 

Tuberculosis of the Nose. — Usually in those suffering from advanced 
tuberculosis elsewhere, has for its seat of preference the cartilaginous 
septum forming at this point usually a single, irregular, superficial, 
persistent, chronic ulcer near the nasal orifice. Around this ulcer 
small, semitranslucent tubercles are sometimes seen. 

A rare form of nasal tuberculosis occurring in those without other signs 
of the disease is in the form of ulcerating vegetation also placed on the 



THE NOSE 275 

cartilaginous septum and at times causing perforation. This is accom- 
panied by enlargement of the submaxillary glands. The distinction 
from syphilis and early carcinoma can be made only by microscopic 
examination of the exsected tissue. 

Tumors of the Nose. — Nasal Polypi. — Nasal polypi, the commonest 
tumors of the nose, constitute jelly-like, usually pedunculated, some- 
times sessile masses, single or growing like a bunch of grapes, and 
varying in size from that of a pinhead to that of a pigeon's egg. They 
usually grow from the middle meatus or the corresponding turbinal bone. 
Exceptionally they are more posteriorly placed on the extremities of the 
turbinals, though they may grow from the frontal, maxillary, or sphe- 
noidal sinuses. 

The affection is one of the adult. It is characterized by discharge, 
obstruction, tendency to bleed slightly on blowing of the nose, and loss 
of the sense of smell, usually unilateral and worse in damp weather. 

When the polyps reach large size they produce pressure distortion or 
frog-like expression to the face. Examination shows the shining gray, 
jelly-like, freely movable masses. 

Osteoma. — Osteoma (commonest in the frontal sinus) may grow from 
any portion of the nasal wall or its accessory cavities. It forms a hard, 
bosselated, irregular tumor of slow growth, which may be very slightly 
or not at all adherent to its point of original outgrowth. Its symptoms 
are those of obstruction if it grows into the breathing passages, or of 
pressure expressed in the form of headache, neuralgia, and deformity, 
the latter dependent upon the direction of growth. Usually manifest 
in the orbit when the growth is from the frontal sinus, pushing the eye 
downward, forward, and outward. Osteoma from the maxillary sinus 
usually projects the cheek. The growth may come from the sphenoid 
or ethmoid sinuses. The diagnosis is based upon the x-rsij picture. 

Epithelioma. — Epithelioma attacking the inner surface of the nostril 
in the form of rodent ulcer is characterized by a slow but destructive 
persistence. Syphilitic lesions are all more rapidly destructive, and 
yield promptly to treatment. The diagnosis should be made, after 
excluding syphilis, by wide removal and microscopic examination. 

Sarcoma. — Sarcoma, particularly upon the septum in young people, 
is characterized by its rapid infiltrating growth, by recurrent bleedings, 
and stinking discharge. The diagnosis should be made on excluding 
syphilis by wide removal and microscopic examination. 

Affections of the Sinuses Communicating with the Nose. — Inflam- 
mation of the Maxillary Sinus. — This is secondary to erysipelas or abscess 
of the face, inflammation of the mucous membrane of the nose, or to 
caries of the teeth, especially the first and second molars. 

When the opening from the antrum into the middle meatus is suffi- 
ciently patulous to prevent tension from retained secretions, the symptoms 
may be confined to a profuse, purulent, intermittent nasal discharge 
running freely when the head is bent well forward, and turned toward the 
sound side, and coming from the middle meatus. 

When the opening into the nose is blocked, in addition to constitutional 



276 THE HEAD, FACE, AND NECK 

symptoms there is severe suborbital pain, often involving the teeth, rapid, 
edematous swelling of the cheek of the affected side, obliteration of 
the canine fossa, and shortly (days) crackling on pressure in this region 
due to erosion of the bone. 

Transillumination, accomplished by an electric bulb held in the mouth 
with the lips closed, will show in a darkened room a shadow in contrast 
to the pink of the healthy side. 

In the direct examination of the nasal cavity the pus is cleared away 
from the middle meatus and the patient is directed to tip the head well 
forward and toward the normal side. A free flow of pus from the middle 
meatus is characteristic of suppuration of the maxillary sinus. 

Finally, if other diagnostic means fail, or in corroboration of these, a 
needle of large caliber attached to an aspirating syringe is passed along 
the inferior meatus to the depth of one and one-half inches, and is driven 
obliquely outward and upward into the maxillary sinus, which is then 
washed out with a boric acid solution. 

As a result of suppuration of the maxillary sinus, particularly that due 
to periostitis of dental origin, fistulse may form, opening into the face or 
the cavity of the mouth. 

Mucous Cysts of the Sinus. — Mucous cysts of the sinus, due, in part, to 
obliteration of its orifice or cystic dilatation of its glands, cause no symp- 
toms, except perhaps preliminary toothache and pressure upon the infra- 
orbital nerve until their growth is sufficient to cause tension. There 
then develops a tumor due to yielding of the bony wall of the sinus in 
all directions. The thin crackling bone finally allows fluctuation to be 
detected. 

Mucous cyst is an affection of young people, and cannot be distinguished 
from malignant growth except by its slow progression, its absence of 
infiltration, and the result of operation. 

Tumors. — ^Tumors originating in the maxillary sinus cannot be recog- 
nized until, by their growth, they displace or infiltrate the bony walls 
and produce deformity, though the frequently associated signs of sinus 
suppuration with pain in the cheek and teeth may even early in their 
course suggest an exploratory operation. 

Myoma, osteoma, fibroma, enchondroma, have all been observed. 
Sarcoma is the commonest malignant tumor starting from the septum 
or the walls of the accessory sinuses, and characterized by rapid progress, 
infiltration, and destruction of the bony envelope, progressive invasion of 
the surrounding soft parts, and, in the case of carcinoma, early involve- 
ment of the cervical ganglia. 

In the carcinomatous form these tumors develop in people past middle 
life, and all are usually characterized by extreme pain. 

Both the benign and the malignant growths cause a sense of weight 
and tension in the face, swelling of the cheek, bulging of the palate, 
obstruction of the nasal fossa, exophthalmos, and loosening and falling 
of the teeth, all expressions of their eroding or infiltrating growth. 

Inflammation of the Frontal Sinus. — Inflammation of the frontal sinus, 
exceptionally traumatic, is secondary to infection of the mucous mem- 



THE NOSE 277 

brane of the nose, particularly that of the middle meatus or to syphilitic 
inflammation of the surrounding bone. 

Acute inflammation, with the infundibulum not entirely occluded, 
is characterized by a nasal discharge and dull pain in the forehead and 
at the root of the nose, greatly aggravated by blowing the nose. When 
the infundibulum is occluded, the pain is severe and may be agonizing in 
its intensity, tenderness over the sinus is marked, best elicited by upward 
pressure at the upper inner angle of the orbit, internal to the supra-orbital 
notch, and there shortly develops swelling in this sensitive region. Or, if 
the septum be incomplete, the swelling may be bilateral. An associated 
osteitis and necrosis allows of pus escape either into the nasal cavity or 
into the orbit, causing in the latter case exophthalmos, orbital swelling, 
and usually the presence of a fluctuating tumor. 

The diagnosis of acute sinusitis with obstruction is obvious. 

Chronic empyema of the sinus gives a free discharge of pus on rising 
in the morning, a dull shadow on transillumination, usually frontal 
headache, often most severe in the morning and subsiding at night, 
much aggravated by intercurrent attacks of nasal catarrh and relieved 
by free discharge, and supra-orbital tenderness and neuralgia. A positive 
diagnosis can be made by catheterizing the infundibulum. This is 
often not practicable until a portion of the midturbinal has been excised. 
Direct examination shows the discharge coming from the middle meatus. 
The a:-rays and transillumination are helpful, at times diagnostic. Men- 
ingitis, brain abscess, and sinus thrombosis are occasional sequelae. 

Tenderness of supra-orbital neuralgia is most marked over the nerve 
trunk, that of frontal sinus disease within this point. 

Tumors. — Tumors of the frontal sinus cannot be detected until they 
cause marked deformity usually of the upper inner orbital wall. 

Inflammation of the Sphenoidal Sinus. — Inflammation of the sphenoidal 
sinus, secondary to rhinitis, particularly that incident to la grippe, polyp, 
and syphilitic necrosis of the body of the sphenoid, is characterized by 
purulent nasal discharge, headache, often referred to the occiput or the 
region of the mastoid, at times by lacrymation, blepharospasm, photo- 
phobia, and optic neuritis. The pus runs back into the pharynx, and, 
being moderate in quantity, crusts in this position. Meningitis, cerebral 
abscess, thrombosis of the cavernous sinus, orbital phlegmon, amaurosis, 
fatal hemorrhage, and retropharyngeal abscess are complications. 

Inflammation of the Ethmoid Cells.— Inflammation of the ethmoid 
cells secondary to nasal infection is characterized by escape of pus from 
the middle meatus if the anterior group be involved, from the superior 
meatus if it comes from the posterior group. There is severe pain felt 
behind the globe of the eye, greatly aggravated by pressure upon the 
base of the nasal bones, and a condition of chronic sepsis. Necrosis is 
a common accompaniment, with intracranial complications. 

Diagnosis is based upon exclusion of involvement of the larger sinuses, 
and particularly the detection of dead bone by means of a probe. 



278 



THE HEAD, FACE, AND NECK 



THE NASOPHARYNX. 

The inflammatory affections of the nasopharynx are those of the nose. 
In addition, it is subject to adenoid and fibromatous growth. 

Adenoid Growth. — ^Adenoid growth is particularly common in catarrhal 
children with big tonsils and enlarged glands of the neck. Heredity 
is a predisposing factor. 

The characteristic symptoms are mouth breathing, which may be 
of immediate serious moment in an infant, snoring, and diflSculty in 
articulating the nasal consonants and their combinations. Children 
thus afl3icted sweat easily and have a stupid apathetic expression. The 
flaccid lower jaw, always swung open, and the short upper lip exposing 
the incisor teeth are characteristic. The ears are often affected from 
the associated nasopharyngeal catarrh. 



Fig. 99 




Anteroposterior section of the head of an adult, showing the situation and gross structure of 
hypertrophy of the lymphoid tissue of the nasopharynx. (Zuckerkandl.) 



If the turbinals be not enlarged these adenoids can be seen by anterior 
rhinoscopy; usually the posterior examination will be necessary, or, if 
this be resisted, the diagnosis can be made by digital examination, though 
in well-marked cases an immobile palate pushed well forward will demon- 
strate the presence of growth behind it. 

Nasopharyngeal Fibroma. — ^This grows usually from the basilar surface 
of the occipital bones of males between the fifteenth and twenty-second 



THE LIPS 279 

years. This age limit does not obtain in the few cases observed in the 
female. It may also grow from the internal pterygoid plate or from the 
upper cervical vertebrse. The symptoms are those of nasopharyngeal 
tumor, i. e., obstruction to breathing, loss of taste, often headache, and 
mucous discharge from the nasopharynx. The examination at this 
stage will usually show the palate depressed and the whole nasopharynx 
filled with a red, nodular, hard, highly vascular, slightly movable growth, 
bleeding readily on examination. The growth is slowly progressive 
(years), displaces and erodes the bones, and invades all the neighboring 
cavities, producing exophthalmos and hideous deformity and ultimately 
signs of intracranial pressure. 

From malignant infiltration the affection is characterized by mobility, 
its comparatively slow growth, absence of ganglionic enlargement and its 
density of structure. It pushes all before it and destroys by pressure, 
but does not infiltrate. These tumors in some cases are fibrosarcomata. 
In the pure fibromata a recessional tendency has been observed after 
the twenty-fifth year. 

Angioma. — ^Angioma has been observed as a rounded, smooth, dark- 
blue, elastic tumor, bleeding readily and freely. 

Chondroma. — Chondromata (rare), characterized by their cartilaginous 
hardness, grow slowly from the cartilages and are prone to recur after 
removal. They are usually mixed tumors. 



THE LIPS. 

Acute Inflammatory Affections. — One or both lips may become suddenly 
hot and swollen without obvious cause as an expression of urticaria. 

Herpes in the form of fever blisters, which, if numerous, are accom- 
panied by distinct swelling, is a frequent accompaniment of gastro- 
intestinal disturbance and may form by confluence one or more thick, 
black crusts, strongly suggesting chancre. The herpetic ulcerations 
should last a week at the most, and appear first as vesicles. 

The crusted lesions of impetigo contagiosa are common about the 
lips. Their sudden development and brief course are characteristic. 

Ulcerations. — A simple ulcer, weather crack, or traumatic fissure of the 
lips may persist for weeks, getting almost well, then recurring. There 
is, however, always a tendency toward progressive betterment. When 
the lesion occurs on the lower lip of a middle-aged man, and in the course 
of weeks slowly grows worse, the diagnosis of its benignancy should be 
made by excision. 

Chancre. — Chancre, characterized by the development (days) of a 
raised indurated ulcer, externally crusted, exhibiting a dirty white, 
closely adherent pseudomembrane on the mucous surface and causing 
disfiguring swelling of the entire lip and early adenopathy, may be mis- 
taken for a simple fissure or a cancer. No simple ulcerative lesion 
develops without obvious cause nor does it progressively increase in size. 
Cancer is much slower in development (months). 



280 



THE HEAD, FACE, AND NECK 



Mucous Patches. — Mucous patches on the inner surface of the hps 
and the corners of the mouth are extremely common. The distinction 
from aphthae is made by their association with other signs of syphiHs. 
In children syphilitic ulceration is often deep enough about the corners 
of the mouth to be followed by radiating cicatrices which form character- 
istic remnants of this disease. 

Gumma. — Gumma of the lips is rare. When it occurs it exhibits 
the features of this affection as seen on other mucous surfaces. 

Tumors of the Lips. — Epithelioma. — Epithelioma usually begins 
at the mucocutaneous junction, sometimes on the mucous surface of the 
lower lip of middle-aged or old men. Exceptionally it is seen in young 
men, in women, and on the upper lip. 

The diagnosis should be made by examination of the excised lesion 
when it is apparently a simple chronic induration, persistent fissure, or 
erosion, or an inflamed scabbing papilloma. 

Fig. 100 




Lymphangioma and hemangioma of the lip and cheek. A soft, bluish tumor exhibiting shot- 
like nodules due to phleboliths. Markedly increased in size by venous congestion of the head. 



Infiltration, fungous outgrowth, rapid extension and involvement of 
lymphatics make the diagnosis absolute and futile. Early glandular 
enlargement should be detected by bimanual palpation, the finger 
of one hand being placed on the mucous membrane of the floor of the 
mouth, but the diagnosis should not be kept in abeyance until this sign 
develops. 

Hypertrophied labial glands, either congenital or acquired, may cause 
a roll of mucous membrane, producing the appearance of a double lip, 



PLATE XV 




Epithelioma of the Lip. (Griinwald. 



THE JAWS 



281 



most perceptible when the upper Hp is retracted as in laughing, sometimes 
large enough to form a projecting mass simulating cancer. 

Angiomata, both venous and arterial, producing great enlargement of 
the lips, are observed in this region. They are often associated with 
lymphangioma producing a condition of deforming hypertrophy called 
macrocheilia. The lymphangioma is usually present at birth, but 
may not constitute a distinct deformity until puberty or afterward. 

Lipoma is shown by its soft consistence and yellow color. It is often 
associated with angioma. 

Adenomata appear as small, hard tumors, single or multiple, placed 
just beneath the mucous membrane. 

Fig. 101 




Mucous cyst of the lip. Duration, months. Opened twice, discharging a viscid, clear mucus. 
Soft, translucent, painless, non-inflammatory. (Hoban.) 

Cysts of the labial salivary glands form small, semitranslucent, rounded, 
non-inflammatory tumors placed beneath the mucous membrane. 

Mixed tumors sometimes develop in this region and are characterized 
by their rapid growth and large size. 



THE JAWS. 



Fractures. — Fracture of the upper jaw, due to direct violence, usually 
involves the alveolar border. Transverse fracture, or detachment of 
the vault of the mouth with the teeth, is characterized by deformity and 
unnatural mobility of the entire dental arch and crepitus. 

Guerin states that tenderness and mobility elicited by pressure upon 
the inner pharyngeal plate are almost diagnostic of this fracture. 

Fracture of the lower jaw, usually in adults, is commonest at about 
the position of the mental foramen and is usually oblique. It may 



282 



THE HEAD, FACE, AND NECK 



be multiple or fissured. The condyloid process is not an unusual seat 
of this injury. 

Fracture of the body of the jaw is usually attended by a deflection of 
the chin toward the affected side and by a marked irregularity in the 
line of the teeth. The anterior portion of the bone is pulled downward 
and backward. The mucous membrane will be found torn at the point 
where the dental arch is broken and crepitus and preternatural mobility 
are readily elicited. 

To elicit mobility and crepitus the jaw is grasped with the thumb 
placed behind the dental arch and the fingers beneath the body. The 
two hands are used, one holding each fragment, the surgeon standing 
behind the patient, who is seated. A break in the continuity can often 
be detected by external palpation alone. 

Fractures of the ramus, attended with little deformity, may be detected 
by combined internal and external palpation. Persistent pain on use and 
deep, fixed, localized tenderness on palpation may be the only symptoms. 

Fractures of the coronoid process are characterized by tenderness, 
slight anterior displacement of the condyle, swelling, and crepitus felt 
immediately beneath the finger, and by great pain consequent upon every 
motion of the joint. 



Fig. 102^ 



Fig. 103 




Fig. 102. — Fracture of lower jaw, through anterior portion of body, in region of canine fossa. 
(Somewhat anterior to the more common seat — see Fig. 103.) Patient an adult male. Note the 
typical deformity — downward displacement of the anterior fragment and elevation of the posterior 
portion. 

Fig. 103. — Fracture of lower jaw, comminuted, at about middle of lateral aspect of body. (A 
very common seat of fracture.) Note the angular deformity and slight over-riding, the loose frag- 
ment, and the atrophy of the alveolar border in conformity with the age of the patient — a female, 
aged sixty-eight years — and following the loss of the teeth. 



1 Figs. 102 to 105. Fractures of the head and neck. Outline drawings from radiographs by Dr. 
H. K. Pancoast in collection of University Hospital x-ray Laboratory; patients referred by or 
from services of Drs. White, Martin, and Carnett, and from dispensaries, and private cases of Dr. 
Pancoast. 



THE JAWS 

Fig. 104 



283 




Fracture of lower jaw slightly in front of angle. (A frequent seat of fracture, but less common 
than farther forward.) Fracture fissured and line oblique and involving socket of second molar 
tooth. There is neither separation nor displacement. Male, aged twenty-two years. 



Fig. 105 




(a) Fracture of the coronoid process of the lower jaw, with separation and upward displace- 
ment of the fragment by the temporal muscle. (6) Multiple fractxu-e of the zygoma of the 
same side. The lines of fracture, indicated by arrows, are posteriorly near the root of the 
process and anteriorly near its junction with the malar bone. There is no displacement vertically, 
but depression would not be indicated in this view, although it could be shown in an anteroposterior 
picture. The injury was due to direct violence. Patient a young adult male. 



284 THE HEAD, FACE, AND NECK 

Inflammation of the Jaws. — Diffuse osteomyelitis of the jaw may 
be either acute, subacute, or chronic. 

Acute Osteomyelitis. — Acute osteomyeHtis may be secondary to trau- 
matism, to exanthemata and other systemic infections, or may develop 
suddenly without ascertainable cause. It occurs in young people about 
the time of puberty. The eruption of a wisdom tooth has seemed to 
be a predisposing factor. The infection, commonest in the lower jaw, 
may involve a part or all of the bone, producing rapid and complete 
necrosis. It is characterized by intense pain, rapid edematous swelling, 
symptoms of profound toxemia, and loosening of the teeth with escape 
of pus from their sockets. 

The prognosis is grave in proportion to the amount of bone involved. 

Acute Osteoperiostitis. — Acute osteoperiostitis, usually secondary to 
dental caries, is characterized by severe pain, local tenderness, and 
swelling associated with pronounced edema of the cheek. The resultant 
abscess usually develops as a gumboil discharging into the mouth. It 
may open externally, forming a sinus communicating with dead bone. 
Exceptionally the infection reaches the deep tissues of the neck and 
spreads rapidly through them, causing brawny infiltration and symptoms 
of profound sepsis. 

Occupation osteoperiostitis and necrosis are observed in those working 
in phosphorus, arsenic, mercury, and mother-of-pearl. Phosphorus 
osteitis, slow in progression and beginning with a toothache, results 
in necrosis characterized by foul discharge of pus from the sides of the 
teeth. 

Arsenical osteitis is characterized by its more rapid course. 

Mercurial osteitis begins as a suppurative gingivitis, and is not usually 
attended by wide destruction of bone. 

Pearl-grinder's osteitis, developing at the age of puberty, is character- 
ized by severe pain and swelling at the junction of the epiphysis and 
diaphysis. 

Osteoperiosteitis may be of the formative type, resulting in great thick- 
ening of the bone with consequent deformity. 

Syphilis of the Jaw. — Syphilis of the jaw is characterized by the forma- 
tion of periosteal gummata, which may result in permanent exostoses. 
Gummata are particularly common on the hard and soft palate, and 
are the usual causes of perforation. Diagnosis is based upon the history 
of the case and the results of treatment. 

Tuberculosis. — Tuberculosis of the maxillary bones may appear in 
the form of chronic alveolar abscess in patients suffering from pulmon- 
ary tuberculosis. The diagnosis is usually made by the microscope. 
Primary tuberculosis of the lower jaw is marked by an indurated 
swelling, attended with little pain, sometimes by stiffness of the jaw. 
Necrosis and fistulization follow, together with cervical glandular enlarge- 
ment. The disease is slow in progression (years), and the diagnosis is 
made by the rr-rays and the tuberculin test. Distinction from sarcoma 
may require an exploratory operation. Sarcoma is more rapid in pro- 
gression, and does not involve the lymph glands, nor does actinomycosis. 



THE JAWS 285 

Actinomycosis. — Actinomycosis of the jaw, usually due to an extension 
from the gums, is characterized by hard, nodulated infiltration of both 
the soft parts and the bone, exhibiting a tendency to multiple sinus forma- 
tion and slow (months, years) but steady extension. In its beginning 
the disease is evidenced by an alveolar abscess differing from those 
incident to ordinary infection only from the fact of its persistence and 
extension to both the soft parts and the bone. Affection of the upper 
jaw is characterized by more rapid extension, loosening of the teeth, 
and early involvement of the antrum. 

The diagnosis is based upon multiple sinus formation, the presence of 
the yellow granules in the pus, and the detection under the microscope 
of the characteristic fungus. When these are not found, cultures may 
be needful. 

Tumors of the Jaw. — Epulis. — Epulis forms a red, easily bleeding, 
irregularly lobulated tumor, growing from the gum or the alveolar border 
between the teeth. It may be fibromatous or sarcomatous in nature, 
as it appears in the young, or carcinomatous in the middle-aged and 
elderly. Diagnosis should be made by complete excision. 

Fibroma. — Fibroma, commonest in the upper jaw, forms a dense tumor 
characterized by indolence, lack of infiltration, and absence of glandular 
involvement. Developing from the interior of the bone it can be dis- 
tinguished from malignant infiltration only by the extreme slowness of 
its progress. 

The diagnosis from sarcoma should be made by excision. 
Chondroma. — Chondroma is characterized by nodular tumor of almost 
bony hardness, extremely slow in progression, and unattended by inflam- 
matory symptoms. It is essentially an affection of early maturity. The 
growth may take place into the maxillary sinus or from the nasal process 
into the nasal chambers. The diagnosis should be made by excision. 
Osteoma. — Osteoma, when situated on the surface, is characterized by 
extreme density and slow growth. Exceptionally, the growth is rapid 
and can then be distinguished from sarcoma only by operation. 

Odontoma. — Odontoma, dependent upon perverted tooth growth, is 
seen at an age before the teeth reach their complete development. 
It may be soft and cystic, fibrous or eburnated. It is extremely slow 
in growth (years), unattended by pain, and exhibits a nodular or bossel- 
ated surface involving the alveolus and projecting on both the outer 
and inner surface of the jaw. The distinction from malignant growths 
should be made by prompt excision. 

Dentigerous Cyst. — Dentigerous cyst, due to the retention of a tooth 
within its follicle, is characterized by a somewhat sharply circumscribed 
swelling, usually of the lower jaw, extremely slow in growth (years), 
and projecting externally. Its growth is most obvious at or after the 
time of second dentition. The cyst may break through the bone, form- 
ing a tumor of considerable size. The diagnosis will be suggested by 
the absence of a tooth not otherwise accounted for, by the a;-rays, and 
by exploratory operation. Similar cysts, unilocular or racemose, may 
develop in connection with a carious tooth. 



286 



THE HEAD, FACE, AND NECK 



Sarcoma. — Sarcoma, commonest in the young, may appear in any of 
its forms, usually growing from the alveolar processes about the incisor 
or canine teeth in the form of epulis. Arising from the upper jaw, it 
exhibits a marked tendency to grow into the maxillary sinus, nose, orbit, 
pharynx, and base of the skull. In the beginning of its development 
sarcoma cannot be distinguished from fibroma. Its rapid growth should 
suggest diagnosis. The variety which begins within the bone substance 
is characterized by persistent pain and localized tenderness. When 
the tumor thins the bone and breaks externally into the soft parts, the 
diagnosis is not difficult. 

Fig. 106 




Osteosarcoma of maxillary sinus. Dense, hard swelling. Four months' duration. Skin 
normal. Bulging of hard palate. No glandular involvement. (Carnett.) 



Carcinoma. — Carcinoma, an affection of old age, may be primary in 
the bones of the jaw or secondary to lesions of the surrounding glandular 
structures. The affection is characterized by pain, which remains fixed 
and is often most severe. Because of the comparatively rapid growth 
(weeks or months) pressure symptoms shortly develop. In the case of 
the upper jaw the nostril of the affected side becomes blocked, there is 
swelling of the corresponding side of the face, and the tumor shortly 
erodes the palate. Exophthalmos and fixation of the eye are compara- 
tively early. Cancer of the lower jaw occasions an earlier involvement 
of the cervical lymph glands than does that of the upper jaw. 



THE JAWS 287 

The Temporomaxillary Articulation. — The temporomaxillary articu- 
lation allows of both a hinge and a gliding motion, facilitated by inter- 
position of an interarticular cartilage, provided on its upper and the 
lower surface with an independent synovial sac. 

Sprains. — Sprains of the temporomaxillary joint are expressed in the 
form of local tenderness and pain on forceful movements. As the 
result of sprain or overuse, or without obvious cause, there may develop 
a noisy joint in the form of a soft or rough crepitus on motion. This 
condition is often not attended with pain, disability, or the subsequent 
manifestations of deforming arthritis. 

Luxation of the Lower Jaw. — The unilateral or bilateral dislocation, 
intracapsular and always forward, may be incident to the muscular 
exertion of opening the mouth widely, to traumatism, producing the 
same effect, or to force exerted from behind when the mouth is open. 

It is characterized by fixation of the jaw with the mouth partly open 
and the chin preternaturally prominent and great pain felt in the temporo- 
maxillary articulation. A hollow can be felt directly in front of the 
tragus in the normal position of the head of the bone. In front of this 
will be found the projection formed by its displacement. In unilateral 
displacement the jaw is deflected away from the injured side. In either 
unilateral or bilateral displacement the lower dental arch projects beyond 
the upper. 

Recurring subluxation incident to a preternaturally mobile inter- 
articular cartilage is attended with a sharp click or jar when the mouth 
is opened widely; at times by pain and fixation readily relieved. The 
condyle is not displaced forward beyond its physiological limit. Many 
people can voluntarily produce subluxation without experiencing pain 
or subsequent discomfort. 

Acute Arthritis. — ^ Acute arthritis, commonly secondary to external 
otitis, suppurative parotiditis, or osteomyelitis of the inferior maxilla, 
may be gonorrheal, rheumatic or a local expression of the infection or 
toxemia of the exanthemata. The symptoms are those common to joint 
inflammation. The jaw is held slightly open and projecting; any move- 
ment causes severe pain. In suppurative cases the pus has a tendency 
to burrow toward the surface of the cheek through either the skin over- 
lying the joint or the external auditory meatus. 

The pyogenic and gonococcal infections often terminate in ankylosis. 
The rheumatic arthritis usually undergoes resolution without subsequent 
stiffness. 

Tuberculous Arthritis. — Tuberculous arthritis is extremely rare. Pain 
and limitation of motion in the temporomaxillary joint, with a slow, non- 
inflammatory swelling exhibiting an ultimate tendency to soften and 
form sinuses are the characteristic features of the affection. 

Chronic Osteoarthritis. — Chronic osteoarthritis, characterized by crepi- 
tation in the joint on forceful movements, and often recurring subacute 
attacks of tenderness and pain, ultimately exhibits the obvious and crip- 
pling deformities of this condition. 

Fixation of the Jaw. — This may be of muscular, fibrous, or bony origin. 



288 THE HEAD, FACE, AND NECK 

Muscular fixation in its temporary form may be an expression of 
hysteria or of central irritation, as in tetanus and trismus. It is usually 
due to inflammation of the jaw^ its joint, or the structures about it. Osteo- 
periostitis and osteomyelitis in either their acute or chronic form are the 
common causes. It is a typical symptom of the eruption of the wisdom 
teeth and accompanies mumps or other parotid inflammation. The con- 
traction may be reflex or due to direct extension of inflammation. In 
the latter case the inflammation, if it be long continued, may result in 
permanent contracture. 

The fixation due to cicatricial contracture incident to extensive 
destruction of soft parts is evidenced by the scars. 

The fixation incident to joint lesions may be fibrous or bony and is 
usually accompanied by contracture of the muscles. Joint lesions of 
the growing period may be followed by imperfect bone development 
characterized by receding chin. The distinction between the fixation 
incident to a contractured muscle and that due to fibrous or bony 
ankylosis of joint origin is dependent upon the history, the x-yslj findings, 
and examination under ether. 



THE MOUTH. 

Inflammatory lesions of the mucous membrane, if multiple and super- 
ficial, are usually thrush or aphthse. Occasionally they are syphilitic. 
The usual cause of stomatitis is defective or erupting teeth. In its ulcero- 
membranous and gangrenous forms it attacks the cachectic, following 
certain of the exanthemata. The chronic ulcers of the mouth are usually 
syphilitic or malignant. The usual tumors are of the same nature. 

Thrush. — Thrush, an affection of young infants, is characterized by 
stomatitis, associated with diffuse, dirty white, superficial patches of 
pseudomembrane, in which can be found the oidium albicans. 

Aphthae. — Aphthae appear in the form of one or multiple superficial, 
painful, tender ulcerations presenting either a red granulating, or gray, 
pseudomembranous surface. Their rapid development, usually in the 
course of some febrile or digestive disturbance, and prompt subsidence 
(days) as the result of cleansing and stimulating treatment, distinguish 
them from mucous patches, which in appearance they may exactly 
resemble. Recurring single aphthous ulcers are common in nursing 
mothers. 

Mucous Patches. — Mucous patches resemble aphthae and are distin- 
guished from the latter by the history of the case, associated signs of 
syphilis, and resistance to cleansing treatment. 

Stomatitis. — Stomatitis, secondary to eruption of the teeth, is character- 
ized by heat, redness, and swelling of the mucous membrane, particularly 
that of the gums, together with profuse salivation. In a localized form 
it may precede and accompany the appearance of the wisdom teeth or 
dental caries. 

Mercurial stomatitis is characterized by metallic taste, foul breath, 
profuse salivation, swelling and bleeding of the gums, and multiple, 



THE TEETH 289 

superficial ulcerations of the mucous membrane appearing as gray 
patches. There is often severe toothache. The submaxillary glands 
are enlarged and necrosis is a common sequel. Diagnosis is based upon 
the history of the case, the local appearance, and the finding of mercury 
in the urine and the saliva. 

Ulceromembranous stomatitis is characterized by the formation of an 
edematous, non-indurated, superficial, pseudomembranous ulceration, 
usually on the inner surface of the left cheek and gums of ill-nourished 
children and young adults, accompanied by enlargement of the sub- 
maxillary lymphatic glands. The affection may spread to the tongue 
or the palate. Exceptionally it causes alveolar necrosis and shedding 
of the teeth. It is distinguished from gangrenous stomatitis by its 
more benign course. 

Gangrenous stomatitis (noma) is an affection of infancy, common 
after measles, sometimes following diphtheria, whooping-cough, or 
scarlet fever, and is an expression of profound dyscrasia. It usually 
begins as a hard, gray, ragged ulcer in the middle of the mucous surface 
of the cheek, and promptly indurates its entire thickness, causing a 
dusky discoloration of the skin surface. Septic symptoms and rapid, 
deep, and widespread sloughing are characteristic. It is distinguished 
from ulceromembranous stomatitis by its rapidly destructive progress, 
greater induration, more extensive edematous swelling, and the more 
pronounced constitutional symptoms. It usually causes shedding of 
teeth and necrosis of bone. 

Mechanical ulcers on the cheeks are fairly frequent as the result of 
sharp or irregular teeth. 

Mucous patches and psoriasis are very commonly placed on the 
inner surface of the cheek, exhibiting here no special characteristics. 
Retention cysts of the mucous glands form small bluish vesicles which 
may be traumatized by the teeth. 

Epithelioma. — Epithelioma of the inner surface of the cheek is com- 
monly on the inner dental line, often upon a patch of leukoplakia. It 
extends with extreme rapidity. 



THE TEETH. 

Dental Caries. — Dental caries, the usual affection of the teeth, is 
noted particularly in the occlusional fissures of the molars and on other 
surfaces not subject to attrition, or readily cleansed. It is in its gross 
form characterized by obvious discoloration, roughening and softening, 
and reaches the maximum of incidence during the growing period. 

The subjective symptoms are incident to exposure of the sensitive 
dentine, and consist of transitory pain caused by sweets, acids, heat, 
or cold. 

The diagnosis is made by direct examination, transillumination, and 
the use of instruments for the detection of softened and sensitive surfaces 
or cavities. 
19 



290 THE HEAD, FACE, AND NECK 

When caries has extended to such depth as to involve the dental 
pulp in inflammation, there develops a continuous pain which may 
have its seat of maximum intensity referred to any of the branches of 
the trigeminal nerve, particularly to the region of the orbit. This pain 
is increased by the application of heat or cold to the diseased tooth. 

A pulp swollen by chronic inflammation may grow through a carious 
perforation of the neck of a tooth and closely simulate epulis. The 
distinction should be made by removal of the fungating mass which 
will be found growing directly from the tooth cavity. 

The symptoms of abscess and gangrene of the pulp are those of root 
abscess with which it is usually associated, together with a loss of normal 
translucency and an insensitiveness to heat and cold. 

Inflammation and Abscess of the Root. — Inflammation of the root of 
a tooth usually incident to caries which has destroyed the pulp without 
providing adequate drainage, or dental procedures which have accom- 
plished the same end, hence commonest in filled teeth, is characterized 
by severe localized pain, aggravated by percussion and pressure upon 
the diseased tooth. The gum is swollen and congested; percussion, if 
this be permissible, gives a dull note instead of the normal resonance, 
and the tooth becomes loosened and slightly extruded. 

Inflammation may be due to traumatism, syphilis, gout, intestinal 
toxemia, or the injudicious use of mercury or iodine. If an abscess 
forms it commonly opens between the gum and the neck of the tooth, 
or at the inner or outer surface of the gum near the affected root. 
There is often an alveolar necrosis, usually limited in extent. 

In the absence of prompt drainage the cheek or submental region 
becomes greatly swollen and an abscess may open externally, or may 
cause a diffuse and fatal form of cellulitis of the neck. 

Severe pain in the region of a tender tooth and marked edematous 
swelling of the cheek of the affected side are the diagnostic symptoms. 
Developing at the roots of the upper teeth, an abscess may open 
into the nose (central incisors) or the maxillary sinus (first and second 
molars). 

Chronic Abscess. — Chronic abscess usually following the acute, at times 
developing in the absence of symptoms of the latter as an expression of 
deficient drainage, is characterized usually by few local symptoms other 
than occasional pain from subacute attacks and some tenderness on 
forceful biting of a hard substance. This lesion is not infrequently 
accompanied by the general toxic or slightly septic condition expressed 
by the term cryptogenic infection. 

The diagnosis is made by passing a probe to the root apex of a tooth 
through a carious cavity and finding pus on the end of the probe, or the 
milking by pressure of a drop of pus either from the space between the 
gum and the neck of a tooth or from a sinus communicating with its apex. 
These sinuses are usually associated with an area of alveolar caries and 
not infrequently open upon the cheek. 

Softening or complete absorption of a tooth root may result from 
apical abscess. Occasionally an extensive osteomyelitis develops. 



THE TEETH 291 

Hyperplasia of the Cementum. — Hyperplasia of the cementiim, incident 
to slight trauma, or the hyperemia of chronic inflammation, is usually 
expressed in the molar roots, appearing in the form of a thickened or dis- 
tinct nodulation. Recurring pain, often severe, without the symptoms 
of inflammation, bettered by biting hard upon substances, may be re- 
garded as significant symptoms. 

This overgrowth is an occasional underlying cause of facial neuralgia, 
and may be attended with a great variety of neuroses. The diagnosis 
should be made by the a;-rays. 

Gingivitis, in its interstitial form, involves both the gum and the peri- 
cementum. It may be caused by local irritation, such as that incident 
to uncleanliness, and the deposit of calcareous material upon the teeth, 
may be an expression of a systemic condition, such as acute or chronic 
infections, gout, rheumatism, intestinal toxemia, or may be of drug 
origin, as from mercury, iodine, and lead. 

The process is expressed by swollen, tender, easily bleeding gums, 
followed by absorption of the alveolar process, the cementum, or both, 
and ultimately resulting in loosening of the teeth. 

Salivary Calculi. — Salivary calculi, appearing in the form of soft, 
dirty white or hard, dark deposits, are made up in the main of phosphate 
of lime, which is readily deposited upon the exposed roots of teeth. The 
outer surfaces of the upper molars and both surfaces of the lower incisors 
are the seats of preference. These deposits occasion gingivitis and often 
alveolar resorption and recession of the gums. 

Pyorrhea Alveolaris. — Pyorrhea alveolaris is predisposed to by gingivitis 
and all conditions which form pockets which favor retention and fer- 
mentation of food. The affection is characterized by calculous deposits 
either at the gum margins or below them, upon the neck and root of the 
tooth, and purulent discharge which can be milked from between the 
gum and the tooth. In its further development the gums may either 
recede, allowing of comparatively free drainage, or the pus pockets 
may progressively deepen. Ultimately the teeth become tender and 
loosened, the pulp is inflamed and destroyed, and apical abscesses may 
develop. Some cases are accompanied by alveolar necrosis discharging 
by sinus near the margin of the gum. 

This condition is at times the underlying cause of profound anemia, 
endocarditis, and the joint and systemic expressions of chronic sepsis. 

Impacted Teeth. — An impacted tooth may cause severe pain, either at 
the point of pressure or referred to the distribution of the branches of the 
trigeminus. The lower third molar, the one commonly at fault, is closely 
related as to its roots with the proximal portion of the inferior dental 
nerve; when, because of transverse position, or because of absence of 
room between the second molar and the ramus of the jaw, obstruction 
is offered to the eruptive efforts, pain, both local and reflex, reaches a 
degree of maximum and crippling intensity. This reflex pain may be 
expressed in the form of tic which may closely simulate that of ganglion 
origin. There is usually an associated local swelling, which may involve 
the whole side of the face, and muscular spasm (trismus). 



292 



THE HEAD, FACE, AND NECK 



The diagnosis is based upon the absence of the wisdom tooth, local 
tenderness, and an x-ray picture. Similar symptoms, but less severe, 
may be characteristic of an unobstructed eruption. 



THE TONGUE. 

The tongue may be absent or may contract vicious adhesions, either 
laterally or to the base of the mouth. 

The frenum may be extremely short or inserted too far forward 
(tongue-tie). These conditions are obvious on inspection. 

Fig. 107 




Showing accessory thyroid gland at base of the tongue. Tumor is nearly spherical, 2,5 x 3 cm. 
Color, grayish red. Microscopic examination shows structure like thyroid- 

Acute Glossitis. — Acute glossitis, due to a spread of infection from the 
mucous membrane, often secondary to erysipelas, typhoid or systemic 
infection, is characterized mainly by rapid (hours) swelling of the 
tongue, accompanied by severe pain greatly aggravated by motion, 
and fever. This infection may start from the lingual tonsil, in which 
case there is rapid edema of the glottis with stridor and dyspnea. It 
usually subsides spontaneously. It may progress to diffuse suppura- 
tion or circumscribed abscess. In the former case the infiltration 
extends down the neck and commonly results fatally either from edema 
of the glottis or septic absorption. 

Mechanical Ulcer. — Mechanical ulcer may be kept up by the irritation 
of a misplaced or irregular tooth, causing first local tumefaction, later 
ulceration, with some swelling of the adjacent tissue. 

Diagnosis is based upon the disappearance of the ulcer or tumor after 
the removal of the exciting cause, or, more safely, when this is chronic 



THE TONGUE 293 

in type and has lasted some time, by excision of the ulcer and its 
microscopic examination. 

Tuberculosis. — Tuberculosis of the tongue is an affection of the adult 
already extensively infected. Ulceration is usually single, at first round 
and superficial, later undermined or punched-out, and extremely irregular 
in shape. About its borders are seen semitranslucent tubercles. The 
submaxillary glands are enlarged. Functional troubles are pronounced 
and the lesions are usually extremely painful, especially from contact 
with irritating foods. 

Diagnosis is based upon the association of the ulcer y^ith other tuber- 
culous lesions, on the tuberculin test when this is applicable, but most 
safely upon excision and microscopic examination, since these growths 
may closely resemble cancer, or, if originally tuberculous, may be the seats 
of malignant degeneration. Exceptionally tuberculosis of the tongue 
appears in the form of small nodules which soften and discharge their 
cheesy contents. Distinction from gumma is based upon the presence of 
associated symptoms. - 

Chancre. — Chancre of the tongue, much rarer than chancre of the lips, 
usually forms a single flattened, circular, or oval rounded lesion with 
indurated base. It exhibits the characteristic features of chancre and is 
distinguished from cancer by its rapid development and early adenopathy 
(days, weeks). 

Mucous Patches. — Mucous patches are usually placed on the borders 
and dorsal surface of the tongue. As a result of irritation from carious 
teeth, they may become distinctly ulcerated and inflammatory. There 
is at times a papillary overgrowth. 

Diagnosis is based upon associated symptoms, rapid course, extent 
and multiplicity of lesions, detection of the spirochete, and the results 
of specific treatment. 

Tertiary Syphilis. — Tertiary syphilis is expressed in the forms of 
diffuse infiltration or gumma. Diffuse infiltration during the process 
of involution causes fissuring and deformity. The tongue presents a 
cracked and irregularly lobulated appearance with patches of epithelial 
desquamation and leukoplakia. 

Gummatous tumors which develop slowly (months), usually on the 
dorsum, are often multiple, occasion but slight subjective symptoms, 
and are prone to soften and discharge before reaching the size of a 
cherry. Distinction from cancer must be based upon the syphilitic 
history, the test of treatment, and, in case of doubt, prompt excision 
and examination, since a differential diagnosis cannot be made from 
the appearance of the lesion. 

Leukoplakia. — Leukoplakia, common in middle-aged men, partic- 
ularly those who smoke and drink and have had syphilis, is an 
expression of chronic inflammation of the mucous membrane. It is 
characterized by the formation of white patches made up of keratinized 
epithelial layer placed upon an area of submucous sclerosis. These 
patches are often combined with ulcerating cracks and fissures. It 
is an occasional predecessor of cancer of the tongue. 



294 THE HEAD, FACE, AND NECK 

Cancer of the Tongue. — Cancer of the tongue is commonest in men 
between the fortieth and fiftieth year and becomes rare after seventy. 
Heredity exercises some influence. 

The favorite seat is on the border of the tongue, particularly that part 
lying close to the molar teeth. When placed farther back and con- 
cealed by the palatoglossal fold the infiltration and ulceration may not 
be detected until the period for operation is past. Pain on movement 
or from the contact of acid foods, and slight bleeding, should suggest 
a careful examination of this region, both by palpation and the use of 
the mirror, since the rapid extension of the growth thus placed makes 
early operation imperative. 

In its well-developed form cancer is unmistakable. It appears as a 
fungating or eroded ulcer, these two conditions being often combined, 
bleeding readily, densely indurated, infiltrating the surrounding tissues, 
and accompanied by an enlargement and hardening of the lymphatics 
in the neck which are prone to suppurate, leaving foul cavities in the 
midst of the infiltrated tissue. There is an atrophic form comparable 
to the scirrhus of the breast in which the progress is slow and cicatricial 
deformity with pronounced atrophy takes place. 

Adenopathy is developed more slowly in the papillary epitheliomata 
which have become implanted on patches of leukoplakia. At times 
the adenopathy is acutely inflammatory in type and is due to infection 
carried from the ulcerating surface and not to cancerous infiltration. 
In all cases it occurs comparatively early in the suprahyoid region and 
in the carotid group of glands. 

Pain of cancer of the tongue rarely becomes prominent until the 
affection is beyond surgical help. When infiltration limits the motions 
of the organ and interferes with both speaking and eating, pain may 
be almost intolerable. It often radiates toward the ear. 

The prognosis of lingual cancer is extremely good, providing it be 
recognized early, i. e., when the diagnosis is made by excision of an 
ulcer simply on suspicion and before it has assumed the malignant type. 
In advanced cases the prognosis is nearly hopeless. 

Actinomycosis of the Tongue. — Actinomycosis may develop primarily 
on the tongue. It is usually secondary to infection of the jaw. It is 
characterized by indurated nodules, at first covered with healthy mucous 
membrane, later softened and discharging pus containing actinomycotic 
granules. Distinction from syphilis and other infiltrations of the tongue 
can be made only by microscopic and cultural examination. 

Tumor and cysts of the tongue, other than carcinoma, angioma, and 
ranula, are rare. 

Arterial and venous angiomata are usually associated with similar 
conditions elsewhere, and are occasionally found at the base of the 
tongue. 

Congenital macroglossia, often unperceived at birth, an affection of 
girl babies, due to lymphangioma, may cause enlargement so great that 
the tongue cannot be contained in the mouth. The part exposed to the 
air presents a hard, dry, corneous surface; that kept moist by mucous 



THE TONGUE 



295 



membrane may exhibit papillary outgrowth or an appearance suggest- 
ing fish-roe. 

Acquired lymphangioma incident to inflammation and developing 
about adolescence may occasion only moderate swelling. The fish- 
roe-like surface is characteristic. 

Lingual Goitre. — Lingual goitre, an affection confined to young 
women, forms a rounded, elastic, vascular tumor in the region of the 
foramen cecum. Its growth is usually associated with an abnormal 
condition of the thyroid. Its position is characteristic. 

Sarcoma of the Tongue. — Sarcoma of the tongue (rare) is characterized 
by the appearance of a rounded, soft, elastic tumor, appearing on and 
part of the tongue, extremely painful, usually growing rapidly, any 
ulcerating before it reaches a considerable size. Exceptionally the 
growth may be extremely slow. Diagnosis is based upon the prompt 
excision of a growth not obviously benign. 

Lipoma. — Lipoma (rare) may be submucous or intramuscular. Be- 
cause of its soft consistency it is usually mistaken for a cyst. The 
growth is slow (years). The diagnosis, unless obvious, should be made 
by excision. 

Fibroma. — Fibroma (rare), found on the dorsal surface of the tongue 
toward its base, may be sessile or pediculated, forming rounded, sharply 
circumscribed, non-inflammatory, very slow growing masses which may 
be soft or hard. The diagnosis, unless obvious, should be made by 



excision. 



Fig. 108 




Ranula, 



Ranula. — Ranula, a retention cyst, usually of the lingual salivary gland, 
forms a sausage-shaped, translucent tumor beneath the tongue and on the 
floor of the mouth. It causes no symptoms nor functional disturbance 
until it reaches large size. It is frequently observed in children. 

A similar cyst due to obstruction of Wharton's duct is character- 



296 THE HEAD, FACE, AND NECK 

ized by the difficulty experienced in probing this channel and by the 
associated swelling of the submaxillary gland. The distinction between 
ranula and dermoid when the latter has reached large development 
may be difficult. 

Dermoid forms a soft, rounded, fluctuating tumor, palpable through 
the floor of the mouth, and shortly forming an external swelling. Ihe 
symptoms are purely mechanical and incident to the size of growth. 
Diagnosis is made by operation. 



THE TONSILS. 

Hypertrophy of the Tonsil. — Hypertrophy of the tonsil, usually symmet- 
rical and associated with chronic lacunar tonsillitis, is obvious on inspec- 
tion. It is mainly troublesome because of recurring acute attacks, 
unless the overgrowth be extreme, in which case there is interference with 
nasal breathing, and swallowing may be difficult. Dependent upon it, 
even in the absence of symptoms, there is often a condition of impaired 
health, and in adults a tendency to recurring attacks of joint inflamma- 
tion of the non-infective type. 

Acute Tonsillitis. — Acute tonsillitis, characterized by swelling, pain 
aggravated by swallowing, often tenderness on external pressure, and 
lymphatic involvement, with constitutional symptoms of acute infection, 
may be catarrhal, lacunar, or parenchymatous. 

The catarrhal affection is characterized by moderate symptoms, both 
local and general, and prompt subsidence. 

The lacunar tonsillitis is characterized by usually sudden onset of 
fever preceded by chill, marked systemic depression, and the appearance 
on the swollen tonsils of dirty white spots or small patches, the present- 
ing surfaces of lacunar plugs. These spots may coalesce to a slight 
degree, but exhibit no tendency to invade the whole tonsillar surface or 
to spread to the pharyngeal walls. 

The distinction from diphtheria should be made by microscopic exami- 
nation of the cultured exudate. 

In its chronic form this inflammation is characterized by repeated 
and causeless recurrences of subacute attacks, often impaired general 
health in the interval, and the appearance of dilated tonsillar crypts, 
some distended and inflamed, others exhibiting yellowish, cheesy masses 
of exudate. These may be concealed by the half arches which, in a 
thorough examination, should be drawn aside. 

Peritonsillar Abscess. — Peritonsillar abscess, the condition to which the 
term quinsy is usually applied, doubtless accompanied by at least a local 
suppuration of the tonsil, is characterized by the symptoms which inaugu- 
rate an ordinary acute tonsillitis; they are mainly suggestive of abscess 
because of their persistence and aggravation. The pain steadily increases, 
making swallowing impossible. Tumefaction is likely to be particularly 
pronounced at first in the lateral region of the soft palate. The uvula 
from edema resembles a large polyp. There may be associated edema 



1 



THE TONSILS 297 

of the epiglottis and the aryepiglottic folds. The diagnosis is based upon 
the sudden onset and rapid (days) progression of symptoms. Incision 
and evacuation of pus with the relief of symptoms is the final test. 

A swelling of the peritonsillar tissues and soft palate may be caused 
by an erupting wisdom tooth. 

Chancre of the tonsil or sarcoma may cause pain equally as great and 
a peritonsillar swelling closely simulating that of abscess. In the former 
case the presence of an ulcer, in the latter the slower onset and non- 
inflammatory character of the growth, is characteristic. 

Ulceromembranous Tonsillitis. — This is usually inaugurated by chill 
and fever and is characterized by the rapid formation of sloughing 
ulceration which may involve tonsils, half arches, and the pharynx, 
but is usually confined to one tonsil. It closely resembles diphtheria 
and syphilis. From the former distinction should be made by bacterio- 
logical examination of the exudate. The sudden onset, the rapid course 
(days), and the absence of specific history or other signs of disease dis- 
tinguish it from the secondary manifestations of syphilis. 

Diphtheritic Tonsillitis. — This is characterized by the formation of a 
pseudomembrane with or without pronounced constitutional symptoms 
of acute infection and enlargement of the cervical glands. The char- 
acteristic feature of the disease is the comparatively rapid spread of the 
pseudomembrane from its area of first appearance to the surrounding 
structures, particularly to the soft palate. At the edge of the spreading 
exudate there is a red inflammatory border of mucous membrane. 

Diagnosis is based upon finding in the exudate the specific bacillus. 

Syphilis. — Chancre. — Chancre of the tonsil is characterized by the 
formation of an ulcer at times phagedenic in type, accompanied by pro- 
nounced enlargement of the gland and the peritonsiUar tissues. The 
diagnosis is based upon the finding of the specific organism in the scrapings 
from the ulcer, the type of early glandular adenopathy, the rapid exten- 
sion of the ulcerating process, often upon the development of secondaries. 

Secondary syphilitic lesions of the tonsil are characterized by their 
extreme pain and their destructive tendency. They can be distinguished 
from phagedenic tonsillitis only by the presence of more characteristic 
associated lesions and by the prompt curative effect of constitutional 
treatment. Ulcerating gummata of the tertiary period are usually, but 
not always, painless. They are deep and destructive in type, and can be 
distinguished from neoplasm only by a history of syphilis, the presence 
of other more characteristic lesions or their scars, and the result of 
constitutional treatment. 

Tuberculosis. — Tuberculosis of the tonsil exhibits no characteristic 
features other than those of chronic inflammation. The diagnosis is 
suggested by associated tuberculous involvement of the cervical lym- 
phatic glands. Lupus of the pharynx is an occasional complication of a 
similar condition of the face and is due to direct extension.. 

Malignant Disease of the Tonsil. — Malignant disease of the tonsil is an 
affliction of adult life. Sarcoma is the commonest form. In its early 
stage it appears much as an h}^ertrophied tonsil, the swelling being 



298 THE HEAD, FACE, AND NECK 

suggestive only because of its rapid development without adequate 
cause and without inflammatory symptoms. Later, the large, readily 
bleeding, infiltrated tumor projecting in the neck is characteristic. 

In the form of lymphosarcoma the tonsil presents a pale, nodular 
appearance. 

The rapid development of other enlarged lymph glands establishes 
the diagnosis of pseudoleukemia. 

The round-cell and spindle-cell sarcomata appear at first simply as 
hypertrophies exhibiting rapid growth. Exceptionally the spindle-cell 
form may be encapsulated. 

Diagnosis is based in the early stage of the affection upon the causeless 
increase in size. 

Carcinoma, an affection of middle and old age, exhibits an early ten- 
dency to ulcerate, involves the cervical lymphatic glands promptly, and 
extends toward the tongue and palate rather than toward the neck. 

The diagnosis should be made by excision. 

In the early stage of malignant infiltration diagnosis should be made 
by excision if syphilis can be excluded. 



THE PHARYNX. 

Pharyngeal Diverticulum. — Pharyngeal diverticulum, due to imperfect 
closure of the branchial clefts, is found with its internal opening either 
in the tonsillar fossa or the pyriform sinus (between the aryepiglottic 
fold and the wing of the thyroid). These diverticulse usually occa- 
sion no symptoms unless they become converted into cysts or fistulse. 
The openings of the latter are usually found anterior to the sterno- 
mastoid muscle and may be as low as the suprasternal notch. 

Foreign Bodies. — Foreign bodies in the pharynx, if large, commonly 
offer no diagnostic difficulty either in regard to their presence or their 
seat. Small foreign bodies often lodge in the recesses of the half arches 
or below the tonsil in the sinus pyriformis, the depression to the side of the 
laryngeal entrance. Placed here they cause a grating feeling, slight pain 
on swallowing, and edema of the aryepiglottic folds often of such extent 
as to occasion dyspnea. 

Diagnosis can be made by palpation or by laryngoscopic examination 
after thoroughly anesthetizing the mucous membrane, unless the swelling 
be so great as to obscure the cause of it. 

Inflammation. — Chronic superficial inflammation of the pharyngeal 
mucous membrane may appear in the hypertrophic or atrophic form. 
The former, usually spoken of as granular sore throat, exhibiting char- 
acteristic glandular and follicular hypertrophies, the latter showing 
smooth, glazed, atrophic mucous membrane. 

Retropharyngeal Abscess. — Acute or subacute retropharyngeal abscess, 
beginning as a periadenitis of the lateral pharyngeal lymphatic glands, 
may be caused by infection of the skin or of any part of the nose or 
mouth, including the tonsil, or may be secondary to the exanthemata 



THE PALATE 299 

or to osteomyelitis of the base of the skull. It is characterized by fever, 
dysphagia, and later dyspnea. Inspection and palpation demonstrate 
the presence of an edematous or fluctuating tumor. It is usually 
observed in childhood, and in the subacute or chronic form is distin- 
guished from tumor by its rapid onset and its age incidence. 

The cold abscess due to tuberculous spondylitis is characterized 
by dysphagia and dyspnea and the formation of a fluctuating, non- 
inflammatory, postpharyngeal tumor. 

Gumma of the Phars^ix. — Gumma of the pharynx, often multiple and 
confluent, forms deep, usually painless, destructive ulcers, followed 
on recovery by marked cicatricial deformity. When the soft palate 
is also involved, and this is common, it may be partly or wholly de- 
stroyed, or become adherent to the pharyngeal wall. 



THE PALATE. 

The palate, particularly its soft part, is the favorite seat of the early 
secondary lesions of syphilis, these appearing in the form of mucous 
patches and reaching their most typical development when placed here 
and on the half arches. Diagnosis is based upon associated symptoms 
of the disease. 

Gummata, the usual cause of perforation of the palate, are char- 
acterized by the appearance of painless, rounded nodulations which 
shortly rupture, discharging, when placed upon the hard palate, a frag- 
ment of bone. These gummata first appear upon the nasal surface of 
the palate. If the soft palate is thus involved, a characteristic symptom, 
nasal regurgitation of food on attempting to swallow, should, if the 
history of syphilis be given, lead to a timely diagnosis. Gummata 
are followed by extensive destruction and troublesome adhesions. 

Perforation of the palate may be caused not only by syphilis, but 
by the erosion of aneurysm, or the infiltration of a tumor from the 
maxillary sinus. 

The tuberculous infiltrations and ulcers of the soft palate are usually 
complications of pulmonary tuberculosis. They form typically indolent, 
slowly destructive ulcers, and are usually so painful as to interfere with 
deglutition. 

Polyps, dermoids, angiomas, and retention cysts are observed in the 
region of the soft palate and pharynx. They occasion no symptoms 
except from their size. 

Hypertrophy of the uvula, obvious on inspection, is sometimes the 
cause of an obstinate unproductive cough. Enormous edema is a 
common accompaniment of the acute anginas, particularly of peri- 
tonsillar abscess. 

The abscess of dental caries not infrequently forms a gumboil on 
the hard palate some little distance from the alveolar border. The 
diagnosis is readily made by inspection or by probing the resultant 
sinus. 



300 I'HE BEAD, FACE, AND NECK 

Mixed tumors develop in young people and may remain almost sta- 
tionary for years. The only symptoms produced are those incident 
to mechanical interference. The growth is usually in the soft palate 
and is slightly nodular, distinctly circumscribed, is hard in some por- 
tions and soft in others, and is covered by a movable mucous membrane. 
Rapid growth is significant of malignant transformation. The diag- 
nosis should be made by removal. 

Melanosarcoma (rare) may in its beginnings simulate the discolora- 
tion of an angioma. 

THE SALIVARY GLANDS. 

Parotid Gland. — ^The parotid gland, roughly triangular in shape, 
lies with its base extending forward from the cartilage of the external 
auditory meatus to a point on the cheek, half an inch to an inch in front 
of the condyle of the lower jaw, and its apex limited by a line drawn 
from the angle of the jaw to the tip of the mastoid process. It dips 
beneath the ramus of the jaw, the temporomaxillary articulation, and the 
mastoid process, and is enclosed in a dense layer of fascia, except at its 
inner portion. 

Lymph glands lie in close contact with both its outer and inner surface 
and also within the substance of its lower extension. 

The salivary secretion is carried into the mouth by Stenson's duct, 
about two and one-half inches long, which lies on the outer surface of 
the masseter muscle, a finger's breadth below the zygoma, curves around 
the anterior border of this muscle, and obliquely penetrates the buccinator 
muscle and the mucous membrane of the mouth, opening opposite the 
second molar tooth of the upper jaw. Near the beginning of this duct 
there is sometimes placed an accessory parotid gland which may be 
present as a separate lobe. 

In the substance of the parotid gland and traversing it lie the external 
carotid artery with its terminal branches, the facial nerve and its branches, 
the great auricular nerve joining the facial, and the auriculotemporal 
branch of the inferior maxillary nerve. 

The normal parotid gland cannot be outlined by palpation. Through 
its duct a fine probe or filiform bougie can be introduced to a depth of 
one or two inches. 

When swollen as a whole, it forms a tumor involving the cheek and 
causing a characteristic projection of the ear; sometimes causing deaf- 
ness by closure of the auditory meatus. 

The Submaxillary Gland. — ^The submaxillary gland lies in a 
pocket of the deep cervical fascia to the inner side of the body of the 
jaw just anterior to its angle. Its upper posterior border is grooved 
by the facial artery. It discharges its secretion through Wharton's duct, 
about two inches in length, opening through a small slit in the side of 
the frenum near its lingual attachment. Into this opening a fine probe 
can be introduced. Because of its position beneath the muscular floor 
of the mouth swellings of glands are apt to appear externally. The 



THE SALIVARY GLANDS 301 

submaxillary gland is best palpated between the index finger of one hand 
passed to the floor of the mouth and the index and middle finger of the 
other hand pressing upward beneath the jaw. 

The Sublingual Gland. — The sublingual gland, placed just beneath 
the mucous membrane of the floor of the mouth, forms at the side of the 
frenum a ridge-like projection which can be seen and felt. It frequently 
sends extensions into the mylohyoid muscle. It discharges its secretion 
through numerous ducts opening at the side of the frenum behind the 
termination of Wharton's duct through an overlying mucous mem- 
brane projection called the plica sublingualis. Swellings of the sub- 
lingual gland project prominently into the mouth. 

General Symptomatology. — The chief characteristic of surgical affections 
of the salivary glands is swelling. This may be inflammatory or non- 
inflammatory in type, may be rapid or slow in onset, may be general, 
involving the whole gland, or may be local, appearing as a tumor. 

General enlargement of the parotid gland, if acute in onset, is usually 
due to mumps or to obstruction of Stenson's duct (calculus or foreign 
body) or to acute infection. 

A general enlargement of gradual onset is incident to chronic inflam- 
mation which may be secondary to duct obstruction. It may be an 
expression of syphilitic or malignant infiltration or may be a feature of 
Mikulicz's disease. 

A localized tumor of the parotid gland, if this be acutely inflammatory 
in type, may be due to an abscess of a portion of the parotid gland; more 
commonly it is incident to suppuration of the lymphatic glands in its 
substance or upon its surface. Tumors formed in the absence of inflam- 
matory symptoms are usually due to inflammatory hyperplasia of the lymph 
glands lying within and upon the parotid. Mixed tumors are the next 
common source of such localized swellings, while cysts, carcinoma, 
gumma, tuberculosis, and actinomycosis are rare. 

Mumps. — Characterized by the rapid (hours) development of a non- 
indurated, extensive, usually bilateral parotid swelling which quickly 
reaches its maximum (one or two days) and subsides without the local 
or general symptoms of pus formation. The submaxillary gland may be 
attacked alone or with the parotid. It may be complicated by orchitis, 
pancreatitis, ovaritis, or mastitis. 

A non-suppurative parotiditis less sudden in onset and more persistent 
in course may be caused by mercury or the iodides, may follow trauma, 
or may develop as an expression of gout or other toxemic condition. 

The diagnosis is suggested by the sudden, apparently causeless onset, 
the exclusion of the usual causes of swelling in this region, i. e., dental 
caries and an erupting wisdom tooth, often by the prompt subsidence of 
the inflammation. 

Acute General Swelling of the Parotid Secondary to Sudden Obstruction 
of Stenson's Duct. — ^This may be the result of salivary calculus, foreign 
body, or an acute exacerbation of a chronic inflammation. 

Calculus, aside from mumps, is the commonest form for an acute 
swelling of the parotid attacking a person in previous health. The pain 



302 



THE HEAD, FACE, AND NECK 



and tumefaction come on while eating, or are greatly aggravated by this, 
and usually subside with a free flow of saliva, to recur again and again. 
The calculus, commonest in young and middle-aged men, may be lodged 
into the duct or one of its subdivisions. It can be palpated by passing the 
thumb into the mouth and the index finger of the same hand on the cheek 
along the course of Stenson's duct (a finger's breadth below the zygoma). 
It is usually shaped like a thin olive stone. 

Foreign body is characterized by the same suddenness of onset; both it 
and calculus are more common in the submaxillary than in the parotid 
duct. Foreign body is a cause of stone and of chronic inflammation of 
the duct, causing thickness, ultimate dilatation, and purulent discharge 
which can be squeezed out. This chronic duct inflammation is char- 
acterized by intermittent attacks of salivary colic. It is sometimes 
associated with emphysematous crackling on pressure over the gland 
(glassblowers). 

In all forms of obstruction the orifice of the duct is swollen and in- 
flamed and pain and swelling are markedly increased while eating. 

The cause of the obstruction, whether it be calculus, foreign body, 
stricture, or chronic inflammation, can be determined by cocainizing the 
oriflce of the duct, milking it of its contents, which should be carefully 
examined, and introducing into it fine probes and bougies. 

Parotiditis secondary to operation or systemic infection develops, as does 
possibly mumps, in a gland predisposed to infection, by extension of 
infection from the mucous membrane of the mouth. It follows, usually 
within a week, abdominal operations, particularly those upon the genital 
tract of women, and is an occasional complication of puerperal fever, 
typhoid, pneumonia, indeed, any of the infectious diseases. 

It begins with pain, swelling, and tenderness of the parotid gland, 
usually of one side, attended with symptoms of sepsis. The jaw may be 
fixed. In patients of dulled sensibilities because of intercurrent disease 
swelling may be the only symptom. The inflammation may gradually 
subside as one, usually many, abscess forms. There may be slough- 
ing of the entire gland. Pus, if not evacuated, may burst into the ear, 
may form a postpharyngeal abscess, involve the temporomaxillary 
joint, or burrow to the mediastinum. If recovery takes place, facial 
palsy and salivary fistulse may follow. 

If only the lower part of the parotid be involved in acute suppurative 
inflammation, this condition cannot be distinguished from a similar one 
attacking the lymphatic glands placed in the parotid or deeply along its 
under surface. A lesion of the nasopharynx, Eustachian tube, or middle 
ear might suggest the probability of a secondary adenitis. 

Syphilitic parotiditis, developing in the secondary stage of the disease 
and characterized by swelling, pain, tenderness, and salivation, has been 
described by Newmann. 

Chronic parotiditis may come on with acute symptoms of moderate 
severity, the primary swelling persisting for weeks and months and grad- 
ually subsiding uninfluenced by treatment. The constitutional symp- 
toms of suppuration are wanting. The condition is diagnosticated by 



THE SALIVARY GLANDS 



303 



the absence of demonstrable cause and its persistence. It cannot be 
distinguished from an infihrating malignant growth except by its more 
rapid onset (hours or days), the prompt involvement of the whole gland, 
and the circumstance that it is not progressive after the first week. 

Symmetrical Enlargement of the Lacrymal and Salivary Glands (Mikulicz's 
Disease). — Mostly observed in the third decade, it is characterized by a 
slow (months or years) enlargement of the salivary and of the lacrymal 
glands. All three of the larger salivary glands, together with the palatine, 
the buccal, the labial, and the Blandin Nuhn gland on the under surface 
of the tip of the tongue may be synchronously involved. 

Malignant infiltration exceptionally causes fairly rapid (weeks), almost 
symmetrical enlargement of the parotid gland which cannot be distin- 
guished from that incident to inflammatory hyperplasia, and may be an 
immediate sequel of the latter. The diagnosis to be of service can be 
made only by excision. 



Fig. 109 




Mixed-cell sarcoma of lymph glands. Duration, six months; non-inflammatory; no pain; no 
tenderness; skin non-adherent; numerous glands enlarged, soft and adherent to one another; mouth, 
nose, throat, ear, eye, and scalp normal. (Hearn.) 



Lymph Glands. — Lymph glands, if enlarged from either inflammatory 
hyperplasia or tuberculous infiltration, when placed in the parotid or 
beneath its deep surface, cannot be distinguished from a beginning parotid 
tumor. Malignant lymphoma, lymphosarcoma, and leukemic lymphoma 
may each begin in the parotid lymphatics. 



304 



THE HEAD, FACE, AND NECK 



Salivary Cysts. — ^These may form at the expense of the duct or of the 
gland substance, and are due to narrowing or obliteration of the passages. 

The duct cyst forms a fluctuating, fusiform swelling in the course of 
Stenson's duct, often associated with enlargement of the gland. 

The gland cysts grow very slowly (years), and are not recognized as 
such until they reach moderate size. They form single, soft, fluctuating 
tumors, incision into which is followed by fistula. 

Congenital Cysts. — Lymphangioma forms an ill-defined, lobulated, 
fluctuating tumor (see Lymphangioma of the Neck), the seat of which 
in the salivary glands can be detected only by excision and examination. 
The same may be said of angioma. 





Via. 110 








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Mixed sarcoma of the parotid, showing typical displacement of the external ear. Duration, 
months. Lobulated and varying greatly in density in the various parts. 

Lipoma may be infiltrating or simply adjacent, lying in the parotid 
space and displacing the gland. In either case the growth is slow (years). 
There is pseudofluctuation and the tumor seems superficial. It has been 
confounded with cyst. 

Fibroma and chondroma exhibit the symptoms of mixed tumors. 

Mixed Tumors. — These may be benign or malignant. They begin at 
any period of life as painless, rounded, movable nodules, often discovered 
accidentally because of a favoring arrangement of lights and shadows. 
They may remain indolent for months or years. This latent period 



THE SALIVARY GLANDS 305 

may be followed by one in which the tumor rapidly increases in size, 
usually toward the surface, exceptionally toward the pharynx, forming 
a bosselated mass, soft in one place, of bony hardness in another, which 
does not infiltrate the surrounding parts, and remains freely movable 
even when the growth has reached large size. 

Pressure symptoms are late in developing. Increased salivation is 
sometimes so pronounced as to be most distressing. The cervical 
lymphatic glands are not involved. These tumors may reach huge size. 

The diagnosis should be made by excision. 

Sarcoma of the parotid should be diagnosticated by excision and micro- 
scopic examination. In its origin and clinical course it closely resembles 
mixed tumor, except the round-cell form, which by a rapid infiltration 
of the whole gland may simulate a subacute parotiditis. This form 
quickly invades the surrounding tissues. 

Carcinoma, either secondary by direct extension from neighboring 
parts or primary in the salivary glands, is predisposed to by previous 
inflammation. It occurs in the encephaloid and scirrhous forms. 

It begins as a hard, at first painless, tumor. The encephaloid form, 
which may develop at any time of life, grows rapidly, forming a large, 
soft, lobulated tumor which shortly breaks through the skin, resulting 
in foul, fungating, bleeding ulcers attended with extensive ganglionic 
enlargement. 

The scirrhous form, an affection of old men, densely infiltrates the 
entire parotid region, retracting the skin and so involving the muscles 
that fixed jaw and wry-neck may be produced. In both forms of carci- 
noma facial palsy, extreme pain, venous engorgement, and difficulty in 
mastication and deglutition develop. 

Diagnosis should be made in the early stage of growth by excision 
and microscopic examination. 

Gumma. — Gumma (rare) forms in the parotid gland a painless, indu- 
rated, slowly growing (months) tumor, infiltrating the skin and surround- 
ing parts, and either softening and ulcerating or undergoing absorption. 
In its early development it exactly simulates malignant infiltration, nor 
can it be distinguished from the latter except by the therapeutic test of 
mercury, time for which should not be taken unless there is a perfectly 
clear history of syphilitic infection. 

Tuberculosis. — Tuberculosis (rare), usually of the lymphatic glands 
lying in or on the parotid, forms an ill-defined tumor which in the 
course of months softens and discharges through one or several sinuses. 
It cannot be distinguished from other tumor formations in the early stages, 
since it may develop in persons free from other signs of tuberculosis. 

Actinomycosis. — Actinomycosis is usually secondary, characterized by 
the typical, dense infiltration, multiple sinus formation, and the finding 
of the characteristic granules in the discharge or in the infiltrate removed 
by operation. 

Salivary Fistula. — Salivary fistula may form in consequence of trauma- 
tism or necrotic inflammation of either the gland or its duct and usually 
closes spontaneously. The diagnosis is readily made by the flow of 
20 



306 THE HEAD, FACE, AND NECK 

saliva through an abnormal opening, increased in quantity by the act 
of eating. 

The Submaxillary Gland.— The submaxillary gland is subject to the 
affections observed in the parotid gland, including mumps. It is in its 
duct particularly that foreign bodies and salivary calculi are found. 

The entrance of a foreign body (fish-bone, fruit-seeds, etc.) is charac- 
terized by sudden pain and swelling of the gland, felt by external or 
bimanual palpation. 

Salivary stone is evidenced by a lump in the floor of the mouth and 
by intermittent attacks of pain and swelling coming on during meals. 
Whether the obstruction be due to stone or foreign body, there is a 
catarrhal condition of the duct with a red, swollen papilla. Inspection, 
palpation, and probing will formulate the diagnosis. 

Mixed tumors of the gland project primarily toward the skin surface 
internal to the body of the jaw just in front of its angle. 

The sublingual glands are particularly subject to cystic dilatation, 
forming the affection called ranula, characterized by a painless, slowly 
growing, semitranslucent, fluctuating tumor in the floor of the mouth, 
commonest in women (see p. 295). 



THE NECK. 

Congenital. — Malformations and Distortions. — (1) Branchial fistulse 
or cysts; (2) skin tabs; (3) teratoma; (4) cervical rib; (5) congenital wry- 
neck. 

Branchial Fistulae. — Branchial fistulse or cysts are due, when placed 
laterally, to imperfect closure of the second branchial cleft; when placed 
centrally, to a persistent thyroglossal duct. They may be complete, open- 
ing upon both the skin and the mucous surface, or incomplete, opening 
upon one surface, or without either opening forming a cyst. Though 
present at birth, they may not produce symptoms until long after. 

The lateral fistula, usually on the right side, forms an indurated cord 
which passes upward beneath the sternomastoid and discharges intermit- 
tently a turbid, mucous secretion, which keeps the surrounding skin in an 
eczematous condition. The surface opening is placed along the inner 
border of the sternomastoid muscle ; the internal opening is in the lateral 
wall of the pharynx near the base of the tonsil, the tract passing between 
the internal and external carotid beneath the digastric muscle and being 
adherent to the sheath of the vessels. 

The injection of an ill-tasting fluid from the external orifice will 
establish the diagnosis. 

Median fistula very rarely manifests its presence at birth. Palpation 
shows an indurated cord in the midline with the external opening 
between the hyoid bone and the suprasternal notch. 

Skin Tabs. — Skin tabs, containing cartilage, at times bilateral, sym- 
metrical, and resembling supernumerary ears, are found along the 
anterior border of the sternomastoid muscle. 



THE NECK 



307 



Teratoma. — ^Teratoma (rare) forms a congenital tumor in the antero- 
lateral region of the neck which cannot be distinguished from goitre, 
since it moves with the larynx. 

Congenital Wry-neck. — ^The expression of a traumatic or toxic myositis 
resulting in fibroid degeneration and contracture of the sternomastoid 
muscle is characterized by drawing of the head toward the affected side, 
while the face, if the sternomastoid be the only muscle contractured, is 
turned toward the healthy side. Any of the muscles of the neck may be 

Fig. Ill 




Congenital torticollis. Right sternomastoid muscle. Typical position. 



involved. Motion is limited and the contracted muscle becomes promi- 
nent when an effort is made to correct the position of the head. As a 
result of the fixed faulty position there is facial asymmetry and later 
curvature of the spine. 

Cervical Rib. — Cervical rib, a malformation growing from the seventh 
cervical vertebra, and with its end free or attached to the first dorsal 
rib, usually causes no symptoms. Exceptionally after puberty in its 
growth it presses on the brachial plexus, causing pain and weakness of 
the arm and a prominence of the subclavian artery which, on examina- 
tion, is found to depend upon an underlying bony swelling distinguishable 
from outgrowth of the first rib or the vertebral processes by the a-rays. 

Traumatisms. — Contusions. — Contusions or sprain of the sterno- 
mastoid muscle causes a blood effusion into its sheath, noted in the 



308 THE HEAD, FACE, AND NECK 

newly born after difficult labor. Trauma of the vertebral column may 
cause contusion or sprain with or without injury to its contents, or luxa- 
tion or fracture with or without injury to the cord (see p. 336). 

Contusions of the Brachial Plexus. — This may follow direct trauma, 
occupation, as from carrying heavy weights on the shoulder, or posi- 
tion (anesthesia palsy), the nerves in the latter case being compressed 
by the clavicle thrown upward and backward, as in the Trendelenburg 
position with arms suspended. It is characterized by anesthesia and 
by palsy of motion. This form of palsy is observed in the newly 
born even when the clavicle has not been broken. 

Contusion of the larynx, such as that produced by a sudden blow 
with the outer border of the hand, may, even in the absence of gross 
lesions, cause sudden death by cardiac inhibition. There are usually 
distinct lesions characterized by bloocj effusion beneath the mucous 
membrane, by edema, and more or less fixation of the cords. The 
immediate effect is dyspnea and intense pain, aggravated by all move- 
ments of the larynx (p. 322). 

A cricothyroid luxation is characterized by intense pain and dyspnea, 
and deformity, usually masked by swelling. 

Fracture of the Larynx. — Fracture of the larynx may occur in children 
and in adults. It usually involves the thyroid cartilage, next in order 
the cricoid, not infrequently both (see p. 322). 

Emphysema favored by coughing may come on immediately, and by 
rapid extension to the mediastinum may destroy life. 

As a result of trauma or forced expiratory efforts, as in coughing, a 
pneumocele may develop. It forms a resonant, sometimes crepitant, 
tumor, the tension of which is increased by expiratory effort. It is 
placed near the course of the trachea or, when it is due to hernia of the 
lung, in the supraclavicular fossa. 

Fracture of the Hyoid Bone. — Fracture of the hyoid bone, commonly 
due to pinching force, is characterized by great pain, local tenderness, 
difficulty in talking or swallowing, and often cough and dyspnea, 
sometimes bloody expectoration from injury of the pharyngeal mucous 
membrane. Either the cornua or the body may be broken. Unnatural 
mobility, and even crepitus, can be detected either by external palpa- 
tion or by examining with a finger of one hand introduced into the 
mouth while those of the other make external pressure. The a:-rays 
will usually show the nature of the injury. 

Vascular Wounds. — Wounds of veins are characterized by free bleeding 
and sometimes the entrance of air by aspiration, particularly if the 
vein walls are adherent to a surrounding infiltration. Ligation of 
one or both jugular veins is not entirely devoid of danger incident to 
back pressure. Ligation of either one or both common carotid 
arteries is likely to be followed by acute cerebral softening, apoplexy 
and death. 

Injury of the thoracic duct, suggested by a continuous flow of chyle 
from the wound, is rarely of grave moment, the flow ceasing spontane- 
ously because of cicatrization and accessory openings. 



THE NECK 309 

Injury to the vagus, if unilateral, is followed by laryngeal hoarseness 
and palsy of the vocal cord, often by pulmonary edema. 

Injury to the cervical sympathetic causes contracted pupil and con- 
gestion and increased temperature on the side of the face. 

Injury of the spinal accessory results in paralysis of the sternomastoid 
and trapezius muscles. 

Affections Characterized by Fixed Positions of the Head. — Acquired 
Wry-neck. — Torticollis may suddenly develop as a result of traumatism. 
It is then due to luxation characterized by bony deformity, to myositis 
incident to blood clot in the substance of the muscle itself, evidenced 
by localized swelling and tenderness, or to deeper blood effusion caus- 
ing irritation of the nerve roots. 

It may be rapid in development and non-traumatic, coming on often 
in the night and due to a myositis, usually termed rheumatic, but 
possibly secondary to any infection. This form of torticollis is common 
in children with slight sore throats and is characterized by a fixed 
position of the head, usually in lateral flexion with slight rotation. The 
muscle affected is tender and rigid to palpation and there is pain on 
motion. The condition is usually transitory, but may become chronic, 
resulting in permanent contracture. 

A similar form of torticollis develops as an expression of rheumatism 
of the vertebral articulations, and is marked by tenderness over the 
spine. 

Torticollis due to gummatous infiltration of the sternomastoid muscle, 
either circumscribed or diffuse, is characterized by the painless pro- 
gression of such an infiltrate in a person giving a syphilitic history. 

Torticollis secondary to caries of the vertebrse is evidenced by more 
gradual onset, fixed position, tenderness over the involved vertebra, also 
elicited by jarring the head downward, and tonic contraction of the 
involved muscles. 

Torticollis secondary to deep cervical adenitis exhibits the additional 
symptoms of glandular inflammation. 

The torticollis symptomatic of a basilar meningitis, mastoiditis, and 
parotitis, or a cerebral hemorrhage involving the motor centres, exhibits, 
in addition to wry-neck, the symptoms of a major condition. 

Spasmodic torticollis characterized by tonic and clonic contractions 
of the muscles supplied by the spinal accessory nerve, occurs in neu- 
rotic individuals, often without definite cause. In the variety char- 
acterized by tonic spasm, the diagnosis can be formulated by excluding 
the usual recognized causes of the contracture, the absence of tender- 
ness or other symptoms of myositis, and often by the development of 
an hypertrophy of the muscles involved. 

Acute Inflammatory Affections of the Neck. — These are mani- 
fested by the rapid development (days) of well-marked local and 
constitutional symptoms of inflammation. If the skin infections be 
excepted, they usually begin in lymphatic glands, and secondarily 
involve the surrounding tissues. Acute osteomyelitis, particularly of 
the lower jaw and mastoid process, exceptionally of the vertebra or 



310 THE HEAD, FACE, AND NECK 

base of the skull, is an occasional underlying cause. Exceptionally the 
infection may occur through puncture or erosion of the esophagus or 
the air passages. 

The acute superficial infections are represented by furuncle and 
carbuncle commonly placed at the back of the neck at the collar line 
and beginning as a follicular infection. Anthrax occasionally develops. 
All of these infections run a characteristic course. 

Acute Adenitis. — Acute adenitis, commonest in children before the 
tenth year, and secondary to a focus of infection in the area from which 
the lymphatics drain into the affected glands, usually develops beneath 
the lower jaw, just behind its angle, or in one or more of the group of 
glands lying high in the neck close to the great bloodvessels. 

Submental adenitis (acute), sometimes called sublingual abscess, 
limited in its extension by the sides of the jaw, forms a tender tumor 
beneath the skin just behind the symphysis. The glands involved 
are the submental group placed between the anterior bellies of the 
digastric on the surface of the myelohyoid muscles. Into them are 
drained the lymphatics of the midportion of the lower lip, chin, gums, 
and floor of the mouth, and the tip of the tongue. They communi- 
cate with the submaxillary group of glands. 

Submaxillary adenitis (acute) forms a tender tumor beneath the 
chin limited in its extension by the body of the jaw and the hyoid bone. 
The submaxillary glands are placed along the inner border of the body 
of the lower jaw, with often one or two glands on its outer surface. 
Lymph to these submaxillary glands flows from the face, the lips, the 
gums, the anterolateral border of the tongue. 

Since the swelling of submaxillary adenitis is likely to extend from 
beneath the jaw slightly on to the cheek surface, it may readily be con- 
founded with an osteoperiostitis of the lower jaw. In the latter case, 
the greatest swelling is to the outer, rather than to the inner, side of 
the base of the jaw and the tumor will be found firmly adherent to the 
bone. The two conditions are, however, often associated. 

Exceptionally, virulent and rapidly infiltrating infection from a carious 
tooth or inflamed tonsil may invade the deep cellular tissues of the 
neck. This is characterized by brawny submaxillary infiltration, 
followed shortly by chill, fever, and symptoms of profound toxemia, 
dysphagia, dyspnea, and fixation of the jaws and head. The floor 
of the mouth is elevated and edema of the glottis is likely to occur. 

This affection is distinguished from an ordinary submaxillary sup- 
purative adenitis by the violence of the local and constitutional symp- 
toms. 

A tender swelling, near or behind the angle of the jaw, accompanied 
by a severe pain, often radiating to the ear, and inability to open the 
mouth, occurring after puberty, and without obvious surface lesion, 
is usually due to an erupting wisdom tooth. The diagnosis is best 
formulated by the a;-rays. 

Superficial Cervical Adenitis. — Superficial cervical adenitis is second- 
ary to infection of the ^ area draining primarily into the subauricular 



THE NECK 



311 



or suboccipital glands, or of the external ear and back of the neck, 
draining directly into the cervical glands placed along the posterior 
border of the sternomastoid and superficial to it. Between these glands 
and the deep set there is a free communication. 

Deep Cervical Adenitis. — Deep cervical adenitis involves the chain of 
glands which pass along the course of the internal jugular vein. The 
upper group of the deep set is made up of many small glands behind 
the sternomastoid, and a few large glands in close relation to the internal 
jugular vein. 



Fig. 112 




Chronic cervical adenitis. Fifteen years' duration; submaxillary group and anterior cervical 
chain of lymph glands enlarged, hard, non-sensitive, and slightly adherent, with normal overlying 
skin. (Carnett). 



Into them is drained the lymph from all the glands placed super- 
ficially and above, and also that from the gums, tongue, tonsils, nasal 
cavity, pharynx, thyroid gland, larynx, and esophagus. The lower 
deep cervical set of glands receives all the lymph from above and that 
from the back of the neck and scalp, the breast and the axilla. 

There develops a swelling beneath the sternomastoid or behind it 
which shortly infiltrates this muscle, fixing the head in a position of 
wry-neck. Since the inflammation is beneath the deep fascia, both 



312 ^ THE HEAD, FACE, AND NECK 

dyspnea and dysphagia may be observed, together with marked con- 
stitutional symptoms. The pus may burrow into the mediastinum, 
may erode a large bloodvessel, or may discharge through the esophagus 
or the air passages. Suppuration of the lower deep group may burrow 
into the axilla. 

The deep cervical glands are subject to suppurative adenitis second- 
ary to infections of the throat, particularly that incident to the erup- 
tive fevers. 

Acute thyroiditis (p. 327) and osteomyelitis of the cervical vertebrae 
(see p. 340) are elsewhere described. 

Affections Characterized by Tumor Formation with Inflammatory 
Symptoms Slight or Wanting. — Inflammatory Hyperplasia. — Second- 
ary to peripheral infection, or engendered by the irritation incident 
to blood absorption, as from simple contusion, or following la grippe 
or other form of toxemia, there may be found one or more small ovoid, 
tender nodules in the position occupied by the lymphatic chains. 
Usually, the hyperplastic glands develop insidiously as the result of pro- 
longed irritation, such as that incident to chronically inflamed tonsils, 
catarrh of the mucous membrane, middle ear disease, or pediculi of the 
head. 

These glands may undergo slow resolution with the removal of the 
source of irritation, or may soften, with practically no inflammatory 
phenomena other than the surrounding induration of a chronic peri- 
adenitis, and either become absorbed or discharge externally. Softening 
takes place before they reach the size of the last joint of the thumb. 

This chronic lymphadenitis resembles, absolutely, the early stages of 
tuberculous adenitis, except that it generally attacks children under ten 
years of age. It predisposes to tuberculous infection. 

If, after the cure of peripheral irritation, the glandular enlargement 
does not subside, the diagnosis should be made by the tuberculin 
test or by excision. 

Tuberculous Lymphadenitis. — Tuberculous lymphadenitis is char- 
acterized by the slow (months), painless enlargement of usually an 
associated group of glands, at times all the glands of the neck. This 
enlargement may remain for a long period hyperplastic in type. It 
may soften and discharge thin curdy pus through a ragged non-indurated 
sinus, or it may extensively invade the periglandular tissues, forming 
an infiltrated, nodular mass discharging through many sinuses. It is 
commonest in the second and third decades of life, and is usually 
observed in the upper superficial or deep cervical group of glands 
from which it extends downward. The tonsil is the common port of 
entrance, and, though in the early stage (weeks) there will be found 
on palpation, perhaps, not more than two or three smooth, movable, 
ovoid nodules, the longest less than the size of the last joint of the thumb, 
at the time these patients are seen by the surgeon the entire side of 
the neck may be found occupied by a nodular infiltration containing 
upward of a hundred diseased glands. 

Tuberculous glands cannot be distinguished from simple inflamma- 



THE NECK 313 

tory hyperplasia in the earliest period of their course. The persistence 
of a chronic enlargement after removal of the focus of infection, par- 
ticularly its increase in size, and the progressive involvement of asso- 
ciated lymphatic glands, occurring in one of tuberculous heredity or 
environment, would strongly suggest the nature of the affection. 

Early diagnosis is important since operation on advanced cases shows 
not more than 75 per cent, of cures. Moreover, lymphosarcoma and 
malignant lymphoma and tuberculous lymphoma, all present precisely 
the clinical picture of simple inflammatory hyperplasia in their begin- 
nings. The diagnosis should be by excision and microscopic exami- 
nation. 

Malignant Lymphoma. — Malignant lymphoma is characterized by hyper- 
plasia, unattended by inflammatory phenomena or characteristic blood 
change except that common in all lymphatic hypertrophy (eosinophilia). 
It is common in children and comparatively young people. It begins 
in the neck, ultimately involving all the glands of both sides in a growth 
at first slow, then at an interval varying from months to years, becoming 
suddenly rapid and progressive. Glands elsewhere may or may not be 
involved. 

The affection is marked by intermittent fever lasting from one to 
three weeks, coming and going without cause. The anemia is toxic. 

In some cases tuberculous adenitis pursues precisely the course .of 
malignant lymphoma. 

Lymphatic Leukemia. — Lymphatic leukemia exhibits similar symptoms 
together with an enormous increase in the blood leukocytes. 

Lymphosarcoma. — Lymphosarcoma often begins in a gland which 
has been previously enlarged and indolent for a long time. It is 
characterized by the rapid growth of a single gland, thus simulating 
the early stage of malignant lymphoma. The size of the original 
tumor steadily progressing, it breaks through its capsule, infiltrating 
the surrounding parts and is likely to ulcerate through the skin by 
pressure or infiltration. The associated chain of glands is not involved. 

A huge soft tumor, occupying the side of the neck, fungating, and 
with metastases, may readily be called sarcoma, but this is no longer 
helpful to the patient. 

The rapid (weeks) and causeless increase in the size of a chronically 
hyperplastic gland, or one previously healthy, should suggest immediate 
removal for diagnostic purposes. This rule should be imperative if 
the gland has, when first seen, reached the size of a pigeon's egg with- 
out signs of inflammation or softening. 

Carcinoma. — Carcinoma of the neck is practically always secondary, 
though there is a primary form developing from a branchogenic cyst 
(rare). Exceptionally the disease develops primarily in the thyroid or 
the thymus. In any event, the presence of a hard, infiltrating tumor 
of the neck, at first non-inflammatory in type, suggests a most careful 
search of the area drained by the lymphatic glands involved. This 
must include the nose, mouth, pharynx, larynx, and esophagus. 

In its earliest stage, carcinoma simulates inflammatory hyperplasia. 



314 



THE HEAD, FACE, AND NECK 



It is at this stage that the diagnosis should be formulated by removal 
of the glands and microscopic examination. 

The late stage is characterized by areas of softening, the formation 
of multiple f ungating sinuses discharging from the extensive induration, 
and the progressive involvement of the glands toward the thorax. 

In the case of an extensive infiltration, often bilateral and riddled 
with sinuses, the diagnosis between actinomycosis, tuberculosis, and 
malignant growth may be difficult. It may be established by find- 
ing the ray fungus, by no means ^easy; by the discovery of the tubercle 



Fig. 113 




Carcinoma of lymph glands. Slo"^^ development during a year after destruction with ' 'cancer 
paste" of an epithelioma of the lower lip. Tumor indurated, nodular and adherent to skin and 
adjacent structures. 

bacillus, often difficult or impossible from the discharges alone; by 
the excision and microscopic examination of a portion of the growth. 
Even this is not always absolutely conclusive. Cervical carcinoma 
of this type is practically always secondary to a primary focus. 

Actinomycosis. — Actinomycosis of the neck is secondary to that of 
the jaw. 

Vascular Goitre. — Vascular goitre may give thrill, bruit, and expansile 
pulsation, and, if it involve an aberrant lobe laterally placed, may closely 



THE NEGIC 



■315 



simulate an aneurysm. It can, however, be lifted away from the carotid 
artery, does not affect the time and tension of the pulse distal to the 
tumor, and is usually associated with symptoms of Graves' disease. 

The Carotid Body. — The carotid body, a small ductless gland of un- 
known function, placed at, or near, the bifurcation of the carotid 
artery, vascularized from this and closely adherent to it, when enlarged 
exhibits a pulsation so pronounced as to suggest aneurysm. Tumor 



Fig. 114 




Bilobular lipoma. Twenty-five years' duration; freely movable; doughy consistence, not connected 
with thyroid; skin dimples when made tense; travelled downward from the neck. (Carnett.) 



of the carotid body arises from the region of bifurcation of the com- 
mon carotid artery beneath the sternomastoid muscle about the level 
of the upper border of the thyroid cartilage. It is moderately movable 
horizontally, but not vertically. It is usually ovoid in shape, is smooth 
and not lobulated, is single and not made up by the coalescence of 
several tumors, exhibits transmitted but not expansile pulsation, may 



316 



THE HEAD, FACE, AND NECK 



give both bruit and thrill, may cause bulging of the wall of the pharynx, 
occasionally contracts the pupil of the same side, grows slowly at first, 
then rapidly, exists for a number of years before causing trouble, and 
is moderately dense in consistence. Inflammatory and subjective symp- 
toms are usually absent. The difficulty encountered in its extirpation 
makes the diagnosis important. 

The pulsation of a cold abscess placed close to the carotid artery 
may so closely simulate that of aneurysm as to require the use of an 
exploratory needle for the formulation of a diagnosis. 

Syphilitic Adenopathy. — ^The early stages of the disease are character- 
ized by a moderate hyperplasia particularly of the postcervical group 
of glands. 



Fig. 115 




Lipoma of neck. Common situation; soft, semifluctuating; skin normal. 



Gummatous adenopathy of the neck is extremely rare. Gummata of 
the skin and subcutaneous tissues of the back of the neck are fairly 
common, and are characterized by skin infiltration followed by early 
softening (weeks) and the formation of one or more deep, punched- 
out ulcers. The diagnosis must be made from epithelioma (rare) by 
associated lesions of syphilis, and by the rapid course, absence of enlarged 
glands, and the characteristic resultant ulcer. 

Lipoma. — Lipoma, commonest in the back of the neck, forms a clearly 
outlined, slowly growing tumor, which, until it has reached large size, 
closely resembles a sebaceous cyst. 



THE NECK 



317 



The diffuse form of lipoma, noted in middle-aged working men, not 
otherwise fat, appears in the form of huge, double chins, supraclavicular 
pads, and great bosses on the back of the neck which may penetrate the 
deep fascia. The diffuse, subfacial lipoma is often congenital, and 
hence may be seen in children as well as in adults. It penetrates mus- 
cular interspaces deeply, sending prolongations along the line of least 
resistance. It often gives the 

sensation of a cystic growth. Fig. no 

Its nature can be determined 
by operation. 

Fibroma. — Fibroma, if super- 
ficial and circumscribed, arises 
from the nerves (neurofibroma) 
or bloodvessels (angiofibroma) 
of the skin and subcutaneous 
tissue, presenting the appear- 
ance of j^6romamoZtocw7?t. The 
diffuse, superficial form appears 
as an elephantiasis. 

The deep form, having for its 
seat of predilection the back 
of the neck, but developing 
elsewhere, is characterized by 
density of structure and slow 
growth. 

Affections Characterized by- 
Fluctuating, Non - inflamma- 
tory Tumor. — Branchial Cysts. 
— Branchial cysts, usually de- 
veloping after puberty, are the 
remains of the thyroglossal 
duct and the second branchial 
cleft. In the latter case they 
are placed at first along the 
anterior border of the sterno- 
mastoid muscle. They may 
form large, soft tumors occupy- 
ing the greater part of the an- 
terolateral cervical region. The growth is slow and non-inflammatory, 
giving pain or discomfort only on pressure. Such a fluctuating growth 
developing in an adult, and not preceded by a solid tumor, can scarcely 
be other than a branchial cyst. Because of their close relation to the 
vessel sheaths the removal of the cysts may be difficult. 

The cyst due to an unobliterated thyroglossal duct is found in the 
midline, between the sternal notch and the foramen cecum at the base 
of the tongue. It can be distinguished from subhyoid or suprahyoid 
bursa only by microscopic examination of its contents. 




Suppurating branchial cyst. Man, aged forty- 
three years; duration four months; slight tender- 
ness; occasional discomfort on swallowing; firm, ill- 
defined, non-fluctuating mass, closely connected with 
surrounding tissue. Overlying skin normal and 
freely movable; regional lymph nodes not involved. 
Diagnosis, microscopic. (Frazier.) 



318 



THE HEAD, FACE, AND NECK 



Dermoids. — Dermoids form small, soft, subcutaneous tumors of slow 
growth, usually in the anterolateral region of the neck, developing after 
infancy. The diagnosis can be made only by excision. 

Congenital Serous Cysts. — Congenital serous cysts, usually observed in 
infants at birth, are due to dilatation of the lymphatic vessels. They are 
multilocular, filled with serum which coagulates on being drawn, are 
sometimes discolored by blood, have no distinct capsule, and penetrate 
deeply and intimately among the various structures of the neck, much as 
does a lipoma. These cysts begin along the inner and outer margin of 
the sternomastoid, and increase in size, often rapidly, forming large, soft, 
fluctuating, at times semitranslucent tumors, which may occupy the 
entire side of the neck and bulge into the axilla. The loculation and 
varying consistency and the presence of fibrous bands in these cysts is 
characteristic. 

Fig. 117 




Subcutaneous cavernous angioma. Slightly elevated compres.sible tumor of indefinite outlines 
on left front of neck, simulating a fibrolipoma on palpation; slow growth since early childhood; 
possesses erectile properties as shown by comparison with accompanying photograph (Fig. 118) 
taken after prolonged expiratory straining effort with glottis closed. (Carnett.) 

Blood Cysts. — Blood cysts of congenital origin may not develop until 
late in life. They form soft tumors often communicating directly with 
large veins, sometimes made up of a mass of varices which may attain 
a size so large as to involve the whole side of the neck, reach to the 
axilla and extend down the anterior wall of the chest. The tension 



THE NECK 



319 



of these cysts is increased by straining efforts, and they can be partly 
emptied of their contents by surface pressure. They do not pulsate. 
There is often an overlying skin angioma. Aspiration may be needful 
for diagnosis. 

Sebaceous Cysts. — Sebaceous cysts form indolent, at first hard, tumors, 
the nature of which is suggested by the distinctly rounded form, super- 
ficial position, close adhesion to the skin, and often the enlarged duct 
entrance from which can be squeezed the sebaceous matter. They are 
commonly placed at the back of the neck near the hair line. Lipoma 
similarly placed may present most of the same characteristics. 

Fig. 118 




Subcutaneous cavernous angioma. Same case as Fig. 117 dui'ing expiratory straining; tense, 
soft swelling showing slight lobulation but no discoloration of skin; scar from an exploratory 
operation during childhood; percussion note higher pitched than opposite side, but tympanitic 
from underlying air passages; spontaneous subsidence of swelling on cessation of straining effort. 
(Carnett.) 



Subhyoid Bursa. — Subhyoid bursa develops slowly and indolently 
beneath the hyoid bone, and cannot be distinguished from a cyst of the 
thyroglossal duct or an accessory thyroid excepting by operation. 
The suprahyoid bursa is indistinguishable from accessory thyroid in this 
position or overdevelopment of the lingual tonsil, since it may be impos- 
sible to elicit fluctuation. 

Chronically Inflamed Glands. — At times glands hyperplastic either from 
long-continued simple irritation or from tuberculous affection, form 



320 



THE HEAD, FACE, AND NECK 



fluctuating tumors entirely wanting in all the obvious signs of inflamma- 
tion. These tumors are, as a rule, multiple rather than single, are sur- 
rounded by the induration of a chronic periadenitis, and will be found to 
have developed at the seat of former hard nodules. 

Sarcoma. — ^Sarcoma may become so markedly cystic as to obscure on 
examination the solid elements of the growth. This is, as a rule, a late 
development, and follows at the seat of a solid or semisolid infiltration. 

Cystic Goitre. — Cystic goitre usually gives the characteristic signs of its 
thyroid origin. When an aberrant lobe undergoes cystic degeneration, 
the diagnosis may be impossible without operation. 







Fig. 119 




.J 


f 


t- 


% 


1 






-4 








m 



Cystic goitre. Duration, years. No subjective symptoms. 



Lipoma. — Lipoma which may be superficial or deep, circumscribed 
or diffuse, usually presents such characteristic features that the diag- 
nosis is obvious. It may, however, especially when placed beneath 
the fascia, appear as a somewhat irregularly outlined tumor, giving 
a sense of fluctuation so distinct as to deceive the elect. It is not infre- 
quently combined with congenital serous cysts. In doubtful cases the 
diagnosis can be made only by operation. 

Affections Characterized by Pulsating Tumor. — Aneurysm.— Any 
tumor of the neck placed near a large artery may exhibit transmitted 
pulsation. When this pulsation is of the expansile type, is associated 
with thrill and bruit, is placed in the course of an artery, and the pulse in 



THE NECK 321 

this artery and its branches distal to the tumor is slowed and lessened in 
tension, the tumor is necessarily an aneurysm. The tumor may be formed 
by the locally dilated wall of the artery (true aneurysm) w^eakened by 
syphilitic or alcoholic arteritis, or by a condensation of fibrous tissue 
adjacent to the wall (traumatic). 

The artery involved is usually the common carotid. Aneurysm of this 
vessel exhibits less of a sex predilection than is noted elsewhere, though 
it is more common in men than in women. It may be associated with 
aneurysmal dilatation of other regions. 

In addition to the typical symptoms of aneurysm (see p. 98), there 
are highly characteristic pressure symptoms expressed in the form of 
vertigo, syncope, and either somnolence or insomnia, pain referred along 
the brachial plexus, hoarseness of the voice, dilatation of the pupil, 
dyspnea and dysphagia, sometimes unilateral palsy, and atrophy of the 
tongue. 

In the aged, especially those who are emaciated, there is commonly 
a fusiform dilatation of the carotid at its point of bifurcation, causing a 
palpable tumor with an expansile pulsation so marked as strongly to 
suggest aneurysm. There is no thrill, but an artificial bruit may be 
caused by even slight pressure of a stethoscope. 

Aneurysm of the internal carotid (rare) forms a pulsating tumor which 
projects into the pharynx. 

An aneurysm of the external carotid is usually traumatic in origin, 
and exhibits the characteristic features of this affection. 

Aneurysm of the subclavian artery forms a transversely elongated 
tumor projecting above the clavicle at the outer side of the sternomastoid, 
its bruit is carried into the axillary artery, and this vessel, together with 
the radial, shows a slowed and softened pulse as compared with the 
corresponding vessels of the healthy side. 

Aneurysm of the innominate artery forms a tumor projecting behind 
the sternoclavicular articulation and often palpable at the suprasternal 
notch; its bruit is carried by both the carotid and subclavian, and both 
those vessels exhibit the characteristic pulse alterations. As in all 
aneurysms, pressure symptoms are well marked and are expressed by 
venous engorgement, muscular spasm or palsy, pain, bone erosion, altera- 
tion of the voice, cough, dyspnea, and dysphagia. The right recurrent 
laryngeal nerve is usually involved. 

Aneurysm of the aorta exhibits little tendency to extend upvv^ard into 
the neck. The symptoms due to pressure upon the brachial plexus and 
the veins are left-sided. The presence of this tumor may be determined 
by the pressure symptoms, tracheal tug, the results of auscultation and 
percussion, and finally by the .T-rays. 

Arteriovenous aneurysm of the neck is usually traumatic and extremely 
rare. It exhibits the characteristic symptoms. 



21 



322 THE HEAD, FACE, AND NECK 



THE LARYNX. 

The symptoms common to affections of the larynx are pain, alteration 
of the voice, cough, and difficulty in breathing. 

The pain is felt in the larynx and may be aggravated by swallowing 
or speaking. Except it be neurotic, it is usually expressive of infiltration 
or inflammation. 

Alteration of voice is characterized by difficulty in striking the true note 
in the case of singers, by hoarseness, or by complete loss of the spoken 
voice. 

Cough due to laryngeal irritation is, in the absence of an ulcerating 
lesion, harassingly recurrent and fruitless. When it is symptomatic 
of trauma or of ulcerative lesions, it is accompanied by an expectoration 
of bloody or sanguinopurulent mucus. 

Respiratory obstruction, if slight, is marked only by noisy breathing. 
In the severe form there is cyanosis and mental perturbation, and the 
noisy breathing is accompanied by violent inspiratory efforts and 
retraction of the suprasternal notch and the intercostal spaces with 
each inspiratory effort. 

Edema of the Glottis. — This is expressed by a swelling of the ary- 
epiglottic folds and base of the epiglottis, narrowing or occluding the 
superior laryngeal orifice, and is a common expression of acute inflam- 
mation of the tongue, throat, tonsils, or laryngeal mucosa, and of 
laryngeal trauma. It occurs as a part of a general edema, may be 
secondary to tumor pressure, and is an occasional dangerous expression 
of angioneurotic edema. 

The symptoms are those of laryngeal obstruction. The diagnosis, if 
not obvious, is made by a laryngoscopic examination. 

Contusion. — Contusion of the larynx is characterized by violent cough, 
dyspnea , and aphonia, exceptionally by sudden death, apparently due t^ 
cardiac inhibition. 

The diagnosis of contusion will be based upon the failure to elicit the 
symptoms of fracture by external manipulation. Laryngoscopic exami- 
nation may show swelling or even blood extravasation, and limitation 
of motion of the vocal cords. The aphonia which frequently results is 
usually transitory. 

Fracture. — Fracture of the larynx, due to direct force, commonly 
involving the thyroid, and appearing as a median or lateral vertical 
break, is characterized by dyspnea, usually dangerous in its intensity, 
cough, often with bloody expectoration, and aphonia. The diagnosis 
is based upon deformity, which is usually obvious, preternatural mobility, 
and crepitation readily elicited except in case of simple fissures or of 
fracture with wide displacement, swelling, tenderness and often the fine 
crepitation of emphysema. The laryngoscopic examination shows 
blood extravasation. 

Tracheal fracture due to direct violence, sometimes to overstretching, 
or to violent coughing, and often associated with laryngeal fracture, 



THE LARYNX 323 

usually appears in the form of a transverse tear, which may be com- 
plete. Profound dyspnea, rapid emphysema, pain, cough, and bloody^ 
expectoration are the symptoms which suggest the diagnosis. 

Bums or Scalds. — Burns or scalds of the larynx, if not immediately 
fatal from cardiac inhibition, cause the dyspnea and aphonia of rapid 
edema. 

Foreign bodies of the larynx are characterized by the sudden onset of 
violent cough and dyspnea. 

Usually the body is extruded by the first coughing act. It may, 
however, become lodged in the larynx, remain movable in the trachea 
or pass into one of the bronchial tubes, usually the right, and remain 
fixed there. 

If the body be lodged in the larynx and not of sufficient size to entirely 
obstruct, it causes recurring paroxysmal cough. There is a temporary 
amelioration of the spasmodic dyspnea after the accident, followed 
shortly by increased difficulty in breathing incident to edema. 

If the body be loose in the trachea, it causes recurring violent paroxysms 
of cough and dyspnea similar in violence and suddenness of onset to 
that characteristic of the first insufflation. 

Lodgement in a bronchus is marked by pain in one side of the 
chest, alteration in the respiratory murmur of the blocked lung, and 
whistling or wheezing at the point of lodgement. 

Diagnosis as to the seat of the body is based upon the history of the 
case, laryngoscopic examination, the use of the bronchoscope, and, 
where this is applicable, the x-rays. 

Inflammation. — Laryngitis. — Acute laryngitis is characterized by pain 
on swallowing or even speaking, referred to the larynx, usually cough 
and hoarseness or loss of voice. 

In its acute congestive form it is exemplified by the croup of chil- 
dren. There is usually here an associated spasm. Diagnosis is based 
upon the usual preceding slight catarrh, suddenness of the attack and 
its rapid disappearance. 

Diphtheritic laryngitis causes obstruction both by edematous swelling 
and the inflammatory exudate. The diagnosis is based upon the 
presence of the membrane containing the specific microorganisms. 

Laryngismus stridulus is characterized by an inspiratory arrest after 
a few straining noisy breathing efforts, followed by cyanosis and shortly 
the resumption of normal breathing. As it is purely spasmodic, the 
attack is sudden in onset and is neither preceded nor followed by the 
symptoms of a laryngeal catarrh. 

Perichondritis. — Perichondritis, usually secondary to gumma, typhoid 
fever, intubation, or tuberculous or malignant infiltration, is character- 
ized by abscess formation, with exposure or discharge of dead cartilage, 
often followed by stricture. Sometimes the rings of the trachea are 
involved. The larynx may be obstructed during the suppurative stage 
or, after healing, incident to scar formation. 

The characteristic symptoms are alteration of the voice, dyspnea, 
and the discharge of pus from an abscess covering dead cartilage, 



324 THE HEAD, FACE, AND NECK 

When the abscess points externally, diagnosis is not difficult. When 
it points internally, the early symptoms are those of obstruction. 

The diagnosis of obstruction, when this occurs to an alarming extent, 
is obvious, but, since the inflammation may be subacute or chronic, and 
attended with few symptoms, a recognition of the cause of obstruction 
is usually dependent upon laryngoscopic examination when this is 
possible, and a consideration of the fact that perichondritis in its 
obstructive form is usually syphilitic or typhoidal, or post-typhoidal. 

Tuberculosis. — Tuberculosis of the larynx is characterized by the 
chronicity of the inflammatory process. It is common in young adults, 
is often unilateral, and attacks by preference that side on which the 
lung is principally involved. It is nearly always secondary to tuberculosis 
of the lungs. 

The characteristic symptoms are alteration of the voice, cough, 
difficulty, often pain, in swallowing, so great as to interfere with the 
patient's nourishment, and the presence of ulcerating infiltrations, par- 
ticularly of the posterior wall of the larynx, the arytenoid cartilages 
and the epiglottic folds. 

The diagnosis from malignant disease is made by examination for the 
tubercle bacilli, and association of these ulcers with other tuberculous 
lesions. 

Lupus. — Lupus is usually secondary. It has been described as form- 
ing papillomatous and ulcerating patches. 

Syphilis. — Syphilis, in its secondary stage, may appear in the form 
of mucous patches, and by a complicating edema may threaten life. 

Gummatous infiltration forms one or more tumors which ulcerate 
before reaching the size of a gooseberry. The usual expression of late 
syphilis is in the form of a disseminated infiltration involving the peri- 
chondrium and ulcerating in patches. The trachea is rarely attacked. 

The diagnosis is formulated on change of voice or its loss, purulent 
blood-stained expectoration, usually little pain (exceptionally severe) on 
swallowing, the detection of ulceration and infiltration on examina- 
tion, the therapeutic test and excision and examination of a portion of 
the infiltrate. 

Stenosis of the Larynx and Trachea. — Stenosis of the larynx and tra- 
chea may be secondary to any ulcerative or destructive process. Trau- 
matism, syphilis, and the perichondritis of infectious fevers, particularly 
typhoid, are the common causes. Tracheotomy, with subsequent long- 
continued wearing of the tracheal tube, is the usual form of traumatism. 

The characteristic symptoms are alterations in the voice, dyspnea, 
and noisy respirations. When the stenosis is due to external pressure, as 
from an enlarged thyroid, aneurysm, or cervical or mediastinal tumor, 
auscultation will usually detect the seat of stridor, there will be signs 
of a mass in the neck or thorax, and the laryngoscope will show a clear 
laryngeal opening. There may be mtiltiple strictures of the larynx and 
trachea. 

Laryngeal Fistulae. — These, when secondary to wound or necrosis 
of the cartilage opening externally, are readily recognized. When 



THE THYROID 325 

opening into the esophagus, usually secondary to the ulceration of 
a foreign body or a carcinomatous infiltration, they are attended by 
the coughing up of ingested food. Gerhardt passes a tube into the 
esophagus not quite to the supposed seat of fistula. Through this tube 
the patient can force air by expiratory effort, as shown by holding its 
external end under water. 

Paralysis of the Recurrent Laryngeal Nerve. — Paralysis of the recurrent 
laryngeal nerve, earliest evidenced in the abductor muscles of the aryte- 
noids, leaves the vocal cords in a midline position, and, if bilateral, 
occasions inspiratory dyspnea. Unilateral involvement may be without 
symptoms other than alteration of voice. Diagnosis is made by laryngo- 
scopic examination. Unilateral palsies are often significant of innomi- 
nate aneurysm, mediastinal tumor, or malignant growth. 

Tumors of the Larynx. — Tumors of the larynx are generally benign. 
Of this class, fibroma and papilloma are the usual ones. Fibroma 
rises from the vocal cords of adults, forming small, rounded, pedunculated 
or sessile growths (years). 

Papilloma, often multiple, presents a characteristic warty appear- 
ance, attacking the vocal cords by preference. Papillomata may be 
single, grouped, or multiple and disseminated. They are commonly 
observed before middle life. 

Retention cysts and angiomata have been observed. 

The characteristic symptoms of benign tumor, if it gives any, are 
alterations of the voice, and the evidences of a persistent or recurring 
slight laryngitis. Exceptionally there is dyspnea. The diagnosis is 
based upon the findings of a laryngoscopic examination, excision, and 
microscopic examination. 

Malignant Tumors. — Sarcoma attacks men of early middle age. In 
its beginning stage it cannot be distinguished from fibroma. Its seats of 
predilection are the bone and false cords and the epiglottis. It is not 
prone to ulcerate or give glandular metastases. Its rapid growth 
(months) is characteristic. 

Carcinoma develops in the middle aged and old (fortieth to the 
eightieth year), exhibiting a predilection for men. The disease is 
characterized by an infiltration which may slowly spread as such. 
Commonly it ulcerates. 

Involvement of surrounding structures and glandular metastases are 
earliest observed in cancer of the vestibule. 

The early symptom of malignant tumor of the larynx is change in 
voice. The diagnosis is based upon laryngoscopic examination by which 
the presence or absence of tumor may be determined. The nature 
of the tumor, unless it be unmistakably benign (papilloma in a young 
person), should be determined by removal and microscopic examina- 
tion. 

THE THYROID. 

The thyroid, a highly vascular, ductless gland, is made up of two 
lateral lobes placed on either side of the trachea and thyroid cartilage. 



326 THE HEAD, FACE, AND NECK 

and an isthmus connecting these two by passing across the front of the 
trachea. Each lateral lobe, about two inches long, extends, with the 
head in its normal position, from the middle of the thyroid cartilage 
to within half an inch of the top of the sternum. The isthmus, about 
half an inch wide, lies in front of the second, third, and fourth tracheal 
rings. From it there is an upward extension, called the pyramidal lobe, 
a remnant of the thyroglossal duct, from which are developed the 
accessory thyroids, found in the region of the hyoid bone or in the base 
of the tongue. There are other accessory glands having slight connec- 
tion or none at all with the thyroid, the commonest position of which is 
behind the sternum. The thyroid may completely encircle the trachea, 
pass behind the esophagus, or by its accessory lobes extend laterally 
into the neck. It varies considerably in size, within normal limits, being 
proportionately larger in infants and in females than in male adults. 

Destruction of the secreting substance of the thyroid, either by disease 
or operation, is followed by myxedema. Its congenital absence or 
disease produces cretinism. Some forms of hypersecretion and over- 
vascularization, and glandular growth, are accompanied by Graves' 
disease. 

The normal thyroid cannot be readily palpated, and any gland which 
may be distinctly outlined, either in part or in whole, is abnormal. 

Aside from the constitutional effect of its glandular degeneration or 
hyperactivity, its enlargement may cause pressure upon the veins of the 
neck, the recurrent laryngeal nerve, the trachea, or the esophagus, 
resulting in cephalic congestion, changes in the voice, and dyspnea; 
dysphagia is rare except from cancer of the thyroid or enlargement 
of a post-esophageal accessory thyroid. 

Lying close to the thyroid capsule, to the outer side and behind the 
lateral lobes, each about the size of a small bean, are the parathyroid 
glands, structures so small as to escape notice, as a rule, and yet fulfilling 
an important function, since the removal of these glands in animals 
causes tetany. There is reason to believe that the same result follows 
when, in the course of operation, they are removed in man. 

The cardinal local symptom of diseases of the thyroid gland is 
tumor in the thyroid region, attached to the trachea and moving with 
it in deglutition. 

Cretinism. — Where goitre is endemic, children are born who, because 
the thyroid gland is either absent or diseased, exhibit characteristic 
dystrophies. There is a dwarfed stature, due to failure of the long 
bones to develop in length, though they reach their normal thickness; 
leathery, loose, dry, hairless, pasty skin, an infantile condition of the 
genitalia associated with sterility, usually idiocy, deafness, and inability 
to articulate. 

Myxedema. — Myxedema, incident to removal or destruction by 
disease of the gland in adults, does not affect stature, but blurs the 
features, indeed, all the body outlines, by a progressive, non-pitting 
thickening of the subcutaneous tissues. From the dry, pasty skin, the 
hair and nails are shed. The pulse is slowed, the hemoglobin below 



PLATE XVI 



/^ 




Lateral View of the Lymphatics of the Tongue Emptying into the Deep 
Cervical Lymph Nodes, some perforating and others passing between the 
genioglossi. 



i 



I 



PLATE XVII 

FIG. 1 



S.T.A. 




Posterior View of Thyroid Gland. Anastomosis between parathyroid 
bodies on both sides. 

.4., anastomosis in posterior surface of pharynx; S.T.A., superior thyroid artery; S.P.B., superior 
parathyroid body; I.P.B., inferior parathyroid body; R.L.N. , recurrent laryngeal nerve. Reduced one- 
sixth natural size. 



FIG. 2 



S.P.B. 



P.A. 



I.T.A. 




S.T.A. 



I.P.B. 

Left Thyroid Lobe Viewed from Behind. Shows unusual position and blood supply 
of superior parathyroid body, rendering body likely of removal in lobectomy. 

S.T.A., superior thyroid artery; S.P.B. , superior parathyroid body; P. A., parathyroid artery; I.T.A., 
inferior thyroid artery; I.P.B., inferior parathyroid body. Reduced one-sixth natural size. 



THE THYROID 327 

normal, the mentality dulled, the virility gone. Puberty is retarded, 
or does not develop when the thyroid is destroyed before this period. 
These symptoms have followed partial thyroidectomy after an interval 
of years. 

Graves' Disease. — Graves' disease is dependent, in part at least, upon 
hypersecretion or perverted secretion of the thyroid. Although it is 
true that experimental lesion of the central nervous system (restiform 
bodies) may produce all the symptoms of Graves' disease, these do 
not develop if previous to such lesion the thyroid be removed. More- 
over, they are cured if after having developed in consequence of such 
lesion the thyroid be extirpated. 

The dominant symptoms of Graves' disease are thyroid enlarge- 
ment, tenderness and murmur, tachycardia, exophthalmos and tremor, 
sweating, vomiting, diarrhea, and often enlargement of the lymphatic 
glands of the neck. These may be present to a degree in any form 
of goitre. Palpitation of the heart is the most distressing and dangerous 
symptom. Soon it becomes complicated by myocarditis, and may be 
associated with angina pectoris. 

Exophthalmos, obvious on inspection, is attended by movement of 
the upper lid, slower than normal, when the patient looks up or down 
(Grafe's sign), abnormal width of the palpebral fissure (Stelwag's 
sign), and impaired accommodation without diplopia (Moebius' sign). 
Kocher regards as an early important symptom a leukopenia (particularly 
of the neutrophilic polymorphonuclears), a percentage and absolute 
increase in the lymphocytes, and an upward flick of the lid, preceding 
by a distinct interval the movement of the eyeball if the examiner's 
hand, held in front of the eye, be suddenly raised. 

Tremor involves the muscles of the trunk as well as those of the 
extremities. 

Neurasthenia is aggravated and pronounced, and usually precedes 
the exophthalmos. Headache and insomnia are common. Excep- 
tionally myxedema develops. 

Postoperative Tetany. — Postoperative tetany, incident to complete 
removal of the parathyroids, closely resembles lockjaw. It has been 
noted immediately after the etherization; usually within the first ten 
days of operation. Stiffness in the legs and arms is prodromal, as is 
sudden contraction of the muscles of distribution on tapping a nerve 
trunk (facial, Chvostek). It is characterized by tonic spasm, par- 
ticularly of the arm and forearm muscles. The attack may pass off 
in a few minutes, may recur frequently, may cause death by spasm of 
the respiratory muscles, or may gradually subside in violence. 

Acute Thyroid Congestion. — Enlargement of the thyroid gland, rapid 
in onset, usually transient, may occur in females at puberty or at any time 
during the period of pregnancy and parturition. It is characterized by 
slight heat, enlargement sufficient to become palpable and often visible, 
possibly some tenderness, and tendency to shortness of breath. 

Acute Thyroiditis. — Either the normal thyroid or its enlargements 
are subject to acute inflammation from trauma or 'as a local expression 



328 



THE HEAD, FACE, AND NECK 



of systemic infection, such as that incident to pyemia, typhoid, articular 
rheumatism, persistent constipation, etc. The diagnosis is easily made 
by the rapid inflammatory swelling of the gland associated with signs 
of pressure, particularly venous congestion of the face, and dyspnea. 
It may undergo resolution, but more commonly suppurates and is not 
infrequently attended with tissue necrosis. Abscess may open externally 
or burrow deep. Its presence will be indicated either by fluctuation 
and surface redness, or by well-marked and progressive systemic symp- 
toms of pyogenic infection. 

The inflammation exceptionally assumes a chronic type, resulting 
in an induration with adhesions to surrounding parts, quite impossible 
to distinguish from cancer, except on microscopic examination. 





Fig. 120 




^,^!^' 


A 






;x^I^^^^Hh ' 1 


I 







Parenchymatous goitre. Duration, months. Subjective symptoms, heart hurry, insomnia, 

and neurasthenia. 

Goitre. — Goitre is usually an acquired affection; occurring congenitally 
and associated with cretinism where the disease is endemic. 

It affects mostly women, is distincdy hereditary, is predisposed to by 
congestion, hence often develops during or after pregnancy, especially 



THE THYROID 329 

when this condition is rapidly recurrent, and in its endemic form is 
supposed to be due to drinking water contaminated with the maritime 
deposits of the "paleozoic and triassic period and the tertiary age" 
(v. Eiselsberg). It may progressively increase in size until it has reached 
huge proportions, may attain a moderate size and remain stationary, or 
may even retrograde. The increase in size may be due to glandular 
proliferation, hypersecretion, or vascular or connective-tissue over- 
growth, commonly to an association of all these conditions. Thus are 
formed parenchymatous or adenoid, colloid (increased secretion), 
fibroid, cystic, and pulsating goitres. The growth may appear as a 
diffuse hypertrophy, the entire gland being enlarged, or in a lobular 
form. 

The Distinguishing Characteristic of Goitre. — A painless, slowly growing 
(years), freely movable tumor, occupying the position of the thyroid, 
attached to the larynx and moving with it, lobular, doughy (colloid), 
fluctuating, or giving pulsation thrill and bruit. Involvement of the 
accessory thyroids, if these be unattached and the thyroid itself be 
healthy, might be suggested by the position of the tumor at the base of 
the tongue, behind the sternum or clavicle, or behind the pharynx or 
esophagus. The administration of iodothyroid might be helpful. 

In the newly born teratoma may move with the larynx and correspond 
in position with an enlarged thyroid. Even in benign goitre of moderate 
size there is usually sufficient venous congestion to cause visible enlarge- 
ment of superficial veins. 

A highly characteristic symptom is dyspnea and noisy breathing on 
slight exertion incident to the sudden swelling due to increased blood 
tension. Sudden attacks of severe dyspnea and acute swelling of the 
goitre are characteristic of hemorrhages into its substance. 

Alterations in the voice, spasms of coughing incident to involvement 
of the recurrent laryngeal nerve and dysphagia suggest malignant infil- 
tration, especially if the symptoms be rapid in progression. Dyspnea 
is rarely dependent upon recurrent palsy, since this must be bilateral 
to cause inspiratory closure of the larynx. 

Toxic symptoms are always present. Insomnia, headache, neuras- 
thenia are commonly associated with rapid heart action. The fibroid 
and cystic forms with destruction of secreting cells and absence of col- 
loid are characterized by tetany and myxedema. The hyperplastic 
glandular form with overvascularization by the typical symptoms of 
Graves' disease. 

Malignant Infiltration. — ^Malignant infiltration usually develops in glands 
already enlarged by goitre. Induration, pain, alteration in the voice, 
dyspnea, dysphagia, and cough with bloody expectoration are character- 
istic of malignancy. Sarcoma and carcinoma are about equally common ; 
both exhibit infiltrating tendency and are rapid in growth, become 
shortly fixed, and are prone to metastases in the lungs and bones, particu- 
larly the sternum, ribs, and skull. 

Sarcoma. — Sarcoma, found in the thyroid in every known variety, 
attacks young people and in the beginning exactly resembles parenchy- 



330 



THE HEAD, FACE, AND NECK 



matoiis growth of one lobe. It may from the first infiltrate the entire 
gland. Its rapid and progressive increase in size is commonly unilateral. 
Infiltration, fixation, and prompt development of pressure symptoms 
(dyspnea, dysphagia, loss of voice, bloody expectoration) establish the 
diagnosis when it is no longer helpful to the patient. During the opera- 
tive stage, i. e., before infiltration and metastases, the diagnosis is possible 
only by excision and examination. 



Fig. 121 




Carcinoma of thyroid. Nodular, fixed, dense, indurated, and of rapid growth (months). 
(C. H. Frazier, service of A. C. Wood.) 



Carcinoma. — Carcinoma customarily begins in one lobe, though 
exceptionally, as in sarcoma, it may attack primarily the entire gland. 
The growth is characterized by rapidity, infiltration, and the prompt and 
progressive development of pressure symptoms. At times the micro- 
scope fails to detect malignancy, this being shown only by metastases. 
Even the metastases may appear benign on section, and from their 
clinical course may functionate as a normal gland, since at least in one 
such case cachexia developed after a sternal metastatic carcinomatous 
growth was secondarily removed (v. Eiselsberg). Metastasis may occur 
when the original growth is very small. 



THE THYMUS GLAND 331 

Scirrhus. — Scirrhus (rare), often of small size, is extremely dense, and 
by infiltration causes early pressure symptoms and enlargement of 
lymphatic glands. 

Malignant infiltration of a benign goitre is characterized by rapid 
growth, increased hardness, pressure symptoms, and lymphatic enlarge- 
ments. 

Echinococcus of the Thjrroid. — Echinococcus of the thyroid (rare) cannot 
be distinguished from cystic goitre except that adhesions to surrounding 
tissues are more marked and dyspnea develops early. It exhibits a 
tendency to discharge into the trachea. 



THE THYMUS GLAND. 

The thymus gland, supposed to disappear at puberty, sometimes per- 
sisting through life, lies close to the trachea in the anterior mediastinum 
and front of the neck, in infants extending from the base of the peri- 
cardium to the thyroid gland. Its function is unknown. 

There are a number of cases of thymus death, by which is meant 
a sudden death from inadequate cause, often preceded and always 
attended by venous engorgement and at times by tracheal stridor, 
occurring in children apparently in vigorous health. These cases of 
death are apparently incident to pressure upon the bloodvessels of the 
neck and secondarily the trachea due to the sudden engorgement of the 
thymus gland. The theory of spasm due to nerve pressure cannot be 
excluded. In children thus afflicted there is usually the condition knowm 
as status lymphaticus, the enlarged thymus is associated, as a rule, with 
general lymphatic enlargement and a flaccid physique. There have 
been reported some cases of chronic dyspnea in early life associated 
with marked venous engorgement and demonstrable enlargement of 
the thymus gland For the relief of this dyspnea the thymus has been 
removed without subsequent changes in the growth or nutrition. 

Sarcoma of the thymus has been observed as a cause of mediastinal 
tumor, the true nature of which could not be detected by any clinical 
sign. 



CHAPTEE XIII. 

THE SPINAL COLUMN. 

The spinal column is made up of a number of closely articulated bones 
firmly bound together, but flexible, allowing a considerable range of 
motion, as a whole, in the direction of anteroposterior and lateral flexion 
and rotation. The position of the spinous processes is marked by a 
median dorsal groove, in which the examining finger, passing from the 
occiput downward, first detects the spinous process of the sixth cervical 
vertebra; next below this, but not always more prominent, lies the seventh; 
the first thoracic spine may be more prominent than either of these. 

The spinous process of the third thoracic vertebra is marked by the mid- 
point of a line connecting the two scapular spines, the arms hanging 
to the sides; of the seventh dorsal vertebra by the midpoint of a line 
drawn across the back between the inferior angles of the scapulae, while 
a line similarly drawn between the highest points of the iliac crests marks 
the position of the fourth lumbar spine. 

The cord terminates in the adult at the lower border of the first lumbar 
vertebra, the dorsal sac continuing as far as the third sacral vertebra 
lying just below a line joining the posterior superior iliac spines. 

At birth the spine has but two curves, the thoracic and the sacral, both 
concave forward and but slightly marked. The two secondary curves 
that develop later are convex forward and placed in the cervical and 
lumbar portions of the spine. There is in addition a slight lateral dorsal 
curve convex to the right. 

The atlas and the axis depart from type, since they are intimately 
associated with the movements of the head upon the spinal column. 
The former bone has no body or spinous process. The latter in place 
of a body has a tooth-like process projecting upward upon which the 
atlas is pivoted. 

The spinal canal containing the cord and its membranes is wide in 
the cervical and lumbar regions where motion is free and the cord large, 
and is narrow in the thoracic region. Between the inner bony wall of the 
canal and the dura is the epidural space, containing bloodvessels and 
cellular tissue. The dura forms a closed sac from the foramen magnum 
to the coccyx, sending a fibrous investment with each nerve root leaving 
the cord. The dura, because of its great strength and loose attachment, 
may remain apparently uninjured, though the cord be crushed by fracture 
or dislocation. 

The transverse process of the atlas can be felt slightly below and in 
front of the tip of the mastoid process. By palpation of the posterior 
pharyngeal wall can be felt the anterior tubercle of the atlas, or, if the 
head be rotated, its arch and the anterior surfaces of the bodies of the axis 
and the third cervical vertebra. 



SYMPTOMATOLOGY OF AFFECTIONS OF THE SPINAL COLUMN 333 

General Symptomatology of Affections of the Spinal Column.— 

Surgical affections of the spine are characterized by pain, tenderness, 
deformity, limitation of motion or fixation, and interference with the 
function and nutrition of the parts supplied by the nerves lying within 
or passing through the spinal canal. 

Fig. 122 




rth cervical vertebra (vertebra prominens). 



Outer end of clavicle. 
A.ciomion process. 

Root of spine of scapula opp. 3d dorsal spine. 
Deltoid muscle and neaa of humerus beneath. 



Teres major m. 

Thin area for auscultation and puncture. 
Latissinaus doisi m. 
Angle of scapula. 



Spinal furrow. 
Erector spinfe muscles. 
Position of kidney. 
Crest of iJium. 



Top of sacrum. 

Posterior superior spine, sacro-iliac joint just 

posterior. 
Greater trochanter of femur. 



Surface markings of the back. (G. G. Davis.) 



The pain may be located at the site of injury, infiltration, or inflamma- 
tion, or may radiate along the course of those nerves the roots of which 
are involved. It is usually aggravated by motion, and it may exhibit any 
grade of severity. 

The tenderness may be elicited by direct palpation, by jarring the 
whole spinal column, or by motion. 



334 THE SPINAL COLUMN 

Tumor, because of the deep position of the spine, is rarely detected in 
its early stages except in the case of meningoceles and myeloceles. De- 
formity is a valuable immediate symptom after fracture and luxation, 
a late one in infiltration or inflammations. 

Limitation of motion is one of the earliest symptoms of all inflammatory 
affections, and is most marked in the region involved. Fixation, with 
demonstrable muscular atrophy, is a late development. 

The symptoms significant of root or cord trauma or inflammation are 
pain referred along the course of the nerves involved, muscular contrac- 
tion, paresis or paralysis, hyperesthesia or tactile, thermic or total anes- 
thesia, exaggeration or abolition of spinal reflexes, and .trophic changes 
which in complete transverse lesions of the cord may be rapid in devel- 
opment. 

Anomalies of the Spinal Column. — Spina Bifida. — Spina bifida 
incident to incomplete development of the lamina of one or all the verte- 
brae, produces a hernia-like protrusion, usually in the lumbar region, 
and often with a portion of the cord closely attached. When protrusion 
is of the pia arachnoid alone, it is called meningocele; when the cord and 
its nerves are contained in the sac, myelomeningocele; when the bulging 
is due to distention of the central canal of the cord, myelocystocele. 
Even though the laminae have not united, there may be no bulging, in 
which case the condition is called spina bifida occulta. 

Meningocele has usually but a single cavity. It escapes through a 
cleft usually narrow and to one side of the midline. There may be no 
symptoms other than the presence of a tumor, often covered with scar-like 
skin, which gives a sense of fluctuation and becomes tense when the 
child cries. 

The meningomyelocele usually exhibits a broad base. Within its sac 
septa can sometimes be felt. 

Spina bifida occulta may be characterized by no symptoms other than 
excessive growth of hair over the defect. 

All these tumor formations are likely to be overlaid by a fatty heman- 
giomatous or lymphangiomatous growth in the subcutaneous tissue. 
There are often associated deformities, such as club foot, epispadia, 
hypospadia, and those incident to paralysis. 

The diagnosis, usually obvious, may be difficult. The distinction 
between meningocele and myelocele may be impossible before operation. 

In the coccygeal region there may be a tail-like extension which may 
contain supernumerary vertebrae, may be made up of soft fibrous tissue 
alone, or of an overgrowth of either skin or hair. The latter condition 
is significant of a cleft in the sacral canal. 

In addition to the teratomata, myeloceles; and meningoceles, in the 
sacrolumbar region overlaid by lipoma, hemangioma, or lymphangioma, 
pure lipomata and lymphangiomata are observed. Moreover, these forms 
of tumor are found on the anterior surface of the coccyx and sacrum. 

The commonest congenital malformation in the region of the coccyx 
appears as a midline dimple or pit incident to the inturning of a skin 
pouch, thus forming a dermoid sac, which is later subject to inflammation 



CURVATURE OF THE SPINE 335 

causing a suppurating sinus, usually mistaken for fistula and distinuished 
from the latter by the fact that it does not communicate with the rectum, 
and particularly by the presence of hair in its walls and in its discharge. 

The tumors and cysts placed on the anterior surface of the coccyx 
and sacrum lying between these bones and the rectum exhibit their 
presence by interference with the function of defecation, and are readily 
detected by digital examination. A cyst due to persistence of a postanal 
gut may reach a size so large as to be detected both by abdominal palpa- 
tion and by inspection of the perineum. 

Cervical Rib. — Cervical rib may be unilateral or bilateral. It is 
incident to a bony outgrowth from the transverse process of the last 
cervical vertebra. Though probably congenital, symptoms may not 
develop until about the period of puberty or thereafter. These are 
essentially those of pressure. They are manifested by pain, neuritis, 
or even palsy in the distribution of the brachial plexus, and exceptionally 
by the production of aneurysm. The affection is usually not recognized 
until pressure symptoms become pronounced. It is detected then by 
palpation and certainly by the a:-rays. In many cases the condition causes 
no symptoms. 

Absence of vertebra has been noted, but in itself occasions no symp- 
toms. It is usually associated with other more obvious deformities. 

Curvature of the Spine. — This may be with its convexity lateral (scoliosis), 
posterior (kyphosis), anterior (lordosis), or combined. 

Lateral curvature, exceptionally congenital, usually beginning between 
the sixth and tenth years, and exhibiting no sex predilection, is usually 
due to an habitual faulty posture, or unequal length of the lower extrem- 
ities. Muscular palsy, thoracic empyema, rickets, osteomalacia, and 
affections resulting in a limp are also common causes. The primary 
curve is usually left convex in the lumbar regions, with dorsal compensa- 
tion in the opposite direction. Or there may be a single lateral bulge, 
called total scoliosis. Associated with the lateral curve there is rotation 
of the vertebrae producing asymmetry of the chest. 

Diagnosis is based upon examination with the patient stripped to 
the top of the trochanters. This affection early shows inequality in 
the height of the shoulders, scapular prominence, elevation of one hip, 
asymmetry of the two sides of the chest, and often deviation of the 
spinous processes from the dorsal vertical furrow. The normal position 
of the spinous processes is indicated by running a line from the mid- 
occiput to the gluteal cleft. There may be considerable rotation without 
marked departure of the spinous processes from this position. The 
dorsal asymmetry of the chest is accentuated by having the patient with 
straight knees bend forward, attempting to touch the floor with the 
fingers. 

Limitation of motion is often an early sign. The patient is directed to 
flex and extend the trunk; to bend it first to one side and then to the other, 
to rotate the shoulders to the right and the left as far as possible. Limita- 
tion in one direction is, in the absence of other cause, suggestive of 
beginning curv^ature. 



336 THE SPINAL COLUMN 

Kyphosis, or convex posterior curvature, is usually postural when not 
incident to antecedent disease, such as tuberculosis or rickets. It is a 
common deformity of youth, is often developed by occupations requiring 
prolonged stooping, and is stated by specialists to be caused by adenoids 
or enlarged tonsils. The deformity is obvious. 

Lordosis is a condition of sway-back which is usually compensatory, as 
in case of bilateral luxation of the hip, or spondylolisthesis, i. e., forward 
and downward displacement of the body of the last lumbar vertebra. 
This malposition is usually symptomless, excepting for undue prominence 
of the sacrum and the iliac crests. It may be an early sign of Pott's 
disease. 

The neurotic spine is characterized by pain, which may be severe 
and localized, particularly in the region of the last cervical vertebra, by 
extreme sensitiveness to pressure, limitation of motion, and general invalid- 
ism. Often there may be an associated curve. Diagnosis is made only 
after prolonged observations and repeated examinations show a want of 
consistency in the symptoms and that they are relieved or exaggerated 
by causes inadequate to so affect a local lesion (see p. 211). 

Trauma of the Spine. — In the absence of fracture or luxation the 
cord is so well protected that it seems scarcely amenable to con- 
cussion. Clinically, however, cases are encountered which, following 
trauma, exhibit primary shock and for a brief period the symptoms 
of a complete transverse lesion of the cord. The complete and rapid 
recovery is the only proof of the absence of a demonstrable cord 
lesion. 

The diagnosis of this rare condition can be made only by the prompt 
convalescence of the patient. Injuries and diseases of the cord and 
roots are discussed under the Nervous System. 

Sprain and Contusion. — Sprains and contusions of the spine are char- 
acterized by pain which is usually severe, is aggravated by motion, may 
give root radiations, and is attended with a protective muscular fixation 
and tenderness, usually fairly well localized. There is no displacement, 
though a previously existing aberration in the contour of the spinous pro- 
cesses may lead to the suspicion that such is of recent traumatic origin. 

Absence of cord symptoms, the transitory nature of the suffering and 
disability, and the relief afforded by strapping, support and massage 
are indices of the absence of a more serious lesion. The symptonis are, 
however, precisely those of fracture without displacement; their persist- 
ence and their aggravation by treatment appropriate to sprain should 
suggest either bone lesion or the onset of a local tuberculosis. 

Fractures and Dislocations of the Spine. — ^These injuries are usually 
combined, though either may exist without the other. They are com- 
monest in vigorous, active men, and usually involve the fourth, fifth, or 
sixth cervical and the last two thoracic and first lumbar vertebrae. 

In fracture the bodies of the vertebrae are the parts chiefly involved, 
and the movement producing the injury is generally one of forced flexion. 
The force applied may be comparatively slight or overwhelming. The 
injury may involve one or several vertebrae. 



FRACTURES AND DISLOCATIONS OF THE SPINE 



337 



The deformity if present is usually in the form of kyphosis or obvious 
backward projection of the spinous processes. In the three upper ver- 
tebrae forward displacement may be detected by examinations through 
the pharynx. There may be lateral deviation. There is always local 
tenderness elicited by direct palpation, percussion, or manipulation of the 
spinous process of the involved vertebra; even slight movement of the 
spine is painful. Crepitus may be felt, but should not be searched for. 



Fig. 123 




Fracture of the cervical spine involving the bodies of the sixth and seventh vertebrae. A 
momentary displacement of one of these bones, probably the sixth, with immediate replacement, 
evidently accompanied the injury, because the cord was severely injured though not severed, 
and the radiograph shows the vertebrse to be in line. Patient a young adult. Cause of the injury- 
was hyperflexion during an attempt to make a ' 'tackle" on a friend during play, but not in football 
practice nor in a game. The anteroposterior view in this case shows no indication of the fractures. 
The lateral view is always the best for determining fractures of the cervical bodies, but it is seldom 
that a radiograph can be made to include as low down as the seventh, as in this case, and often it 
is impossible to show below the fifth vertebra, where fractures usually occur. 



Cord injury is expressed by motor, sensory, and reflex phenomena, 
which, if due to the crushing force of displaced bone, are instantaneous 
in development and more or less permanent; if caused by hemorrhage, 
symptoms develop more slowly (minutes, hours) ; if by traumatic reaction, 
still more slowly (days, weeks, months). 

Complete transverse lesion, usually but not always indicative of frac- 
ture dislocation, is characterized by flaccid palsy of the parts supplied by 
that portion of the cord lying below the seat of injury and by complete 
absence of tendon reflexes. Death is immediate from asphyxia when 
the first four segments of the cord are involved. In lesions lower down, 
above the line of anesthesia, there is usually a zone of hyperesthesia 
incident to irritation of the undestroyed roots and cord immediately 
adjacent. Localizing symptoms are given in the section devoted to the 
Nervous System (p. 190). 
22 



338 



THE SPINAL COLUMN 



Lesion of the cord, either partial or completely transverse, has been 
observed in the absence of either fracture or demonstrable luxation, this 
condition being accounted for by a luxation which was immediately 
reduced. 

Dislocation unaccompanied by fracture is noted almost solely in the 
cervical region involving chiefly the fourth, fifth, and sixth cervical 
vertebrae. The dislocation is commonly unilateral, and is due to a twist- 
ing force, the lower articular cartilage of the displaced vertebra riding 
forward over the cartilage below it and either resting upon its anterior 
border or dropping into the depression in front. This necessarily implies 
at least a sprain of the intervertebral articulation of the other side. 



Fig. 124 



Fig. 125 




Left subluxation of the fifth cervical vertebra. (Von Bergmann.) 

The condition is characterized by severe pain which may be most 
marked in the lateral articulation least involved. The pain is greatly 
aggravated by motion, particularly such as tends to increase the char- 
acteristic rotation and lateral flexion of the head toward the sound 
side. Deviation of the spinous process from the midline can sometimes 
be felt. Increased prominence of the body of the vertebra and the 
lateral process on the dislocated side is readily palpable through the 
posterior pharyngeal wall in the case of the upper vertebrae. The 
findings of the ir-rays are conclusive. This luxation may undergo 
spontaneous reduction during etherization. 

When the luxation is complete and bilateral there will be an anterior 
deformity and forward projection of the displaced vertebra, and flexion 



FRACTURES AND DISLOCATIONS OF THE SPINE 339 

at the seat of displacement, though this may be concealed by compensa- 
ting extension of the vertebrae above. 

Partial or complete dislocation of the atlas and axis are reported 
incident to forced flexion or rotation, usually attended with fracture, 
especially of the odontoid, and commonly resulting in immediate death. 
Because of the roomy canal in this portion of the spine the cord may be 
but slightly or not at all pressed upon. The head fixed in flexion, the 
deformity, recognized by examination of the pharyngeal wall, and the 
results of an .T-ray examination would establish the diagnosis. When 
such injuries are suspected, movements of the head for diagnostic pur- 
poses are contra-indicated. 

Fracture unaccompanied by dislocation usually of the vertebral bodies 
exhibits the symptoms of severe sprain with more pronounced and 
persistent local tenderness best elicited by percussion or manipulation 
of the spinous process. Deformity, if present, appears in the form of an 
unnatural prominence of the spinous process of either the fractured ver- 
tebra or the one above or below the seat of fracture. This deformity 
immediately after the injury is lessened or caused to disappear on 
extension; it becomes permanent from ankylosis on recovery. The 
a;-rays may be diagnostic. 

Though the presence or absence of lesions of the spinal cord is of 
major importance, the determination as to whether or not the bone has 
been broken by violence in the absence of such lesion is essential, since a 
failure to recognize fractures of the bodies of the vertebrse or of the inter- 
vertebral disks without displacement, and therefore a neglect to secure 
rest sufficiently prolonged for complete healing, is probably responsible 
for post-traumatic spondylitis (see p. 342). 

When the spinous processes are fractured, usually from direct violence, 
preternatural mobility and crepitus may be elicited. Fractures of the 
laminae are of major importance only if they be complicated by external 
wound or cord symptoms. 

. Fracture Dislocations. Forced flexion, as from a fall backward on the 
head and neck, is prone to cause a forward dislocation of the fourth, 
fifth, or sixth cervical vertebra, with an oblique fracture of the body of 
the vertebra below it, the plane of fracture running from above down- 
ward and forward, so that the displaced vertebra carries the fragment 
forward with it. This is the type of dislocation fracture commonly 
observed in the lower cervical and upper dorsal regions, and, because 
of the wide displacement favored by the fracture, the cord is generally 
involved. 

Impact and forced flexion in the dorsolumbar region, as from a heavy 
fall on the buttocks or feet or the imposing of an overwhelming weight 
on the shoulders, causes a crushing fracture of the bodies of one or more 
of the dorsolumbar vertebrae, particularly the eleventh, twelfth, and first, 
which may or may not be complicated by dislocation. In the former 
event there may be no cord symptoms, or, because of a backward displace- 
ment of a bone fragment, these may be pronounced. In the latter case 
the symptoms are usually those of more or less complete transverse lesion. 



340 THE SPINAL COLUMN 

The diagnosis of fracture dislocation is based upon the undue promi- 
nence of the spinous processes, with or without lateral deviation, local 
tenderness, pain both local and radiating, usually total disability, and 
frequently the evidence of local cord lesion. The x-rays may be abso- 
lutely diagnostic. 

Wounds of the vertebrae are usually detected by direct examination. 
Gunshot wounds with modern weapons are of particular importance 
because of the associated cord lesion, which may be completely trans- 
verse even though the bone be not extensively shattered. 

Inflammation of the Spine. — Acute Suppurative Spondylitis. — Acute 
osteomyelitis of the spine is an affection of youth, commonest in the 
lumbar region, and most likely to develop in the bodies of the vertebrae, 
though it may involve any portion. It may follow either slight or severe 
trauma; the source of infection can often be traced to a preceding boil, 
carbuncle, sore throat, or suppurating area. 

It is characterized by the constitutional symptoms of pronounced 
sepsis, being usually inaugurated by chill and high fever. There is local 
fixation of the spine, tenderness to palpation, though the latter may not 
be marked, and severe pain aggravated by motion and radiating along 
the course of the nerves the roots of which pass close to the infected 
area, often associated with muscular spasm. 

In the cervical region torticollis and rigidity develop early, and are 
soon followed by postpharyngeal swelling, which makes both swallowing 
and breathing difficult. 

In the thoracic region a secondary pleural effusion is quickly formed 
and usually obscures the diagnosis. Rigid belly walls and extreme pain 
may also suggest peritonitis. 

Diagnosis is based upon the violent onset of the septic symptoms, their 
persistence and aggravation, the localized tenderness and fixation of the 
spine, and the elimination of other causes for the condition, such as mas- 
toiditis, or meningitis. The pleural effusion secondary to involvement 
of the thoracic vertebra, at first purely serous, later becomes purulent. 
A pleurisy has neither the stormy onset, the vertebral fixation and ten- 
derness, the pain radiations and muscular spasm, nor the progression 
of symptoms after tapping. When the vertebral bodies are involved 
in an acute osteomyelitis, the prognosis, grave at the best, is almost 
absolutely bad in the absence of early intervention, death being from 
sepsis or meningitis. 

Tuberculous Spondylitis. — ^Tuberculosis of the spine|^attacks by prefer- 
ence male children before puberty, being most frequent before the fifth 
year, though it may develop at any period of life. The seats of prefer- 
ence are the anterior portions of the bodies of the lower thoracic and 
upper lumbar vertebrae and their intervertebral cartilages. It may 
involve simultaneously more than one portion of the spine. From dis- 
integration of the anterior vertebral bodies and their cartilages angulation 
results, forming kyphosis, which, when several vertebrae are involved, may 
appear as a rounded bulging. Abscess usually forms and may reach 
huge size. 



TUBERCULOUS SPONDYLITIS 341 

Of the upper cervical vertebrae, the axis^is the one most frequently 
affected, the resulting abscess, if one develops, appearing behind the 
pharynx and producing difficulty in swallowing and breathing. It may 
burrow downward into the posterior mediastinum, or open to the inner 
or outer side of the lower attachment of the sternomastoid musclC; or 
even present at the arm pit. 

The abscess of dorsal caries exceptionally presents along the course of 
the ribs. It is more prone to follow the course of the great vessels, pre- 
senting in the groin, exceptionally on the buttock. The abscess of dorso- 
lumbar origin follows the course of the psoas muscle, presenting beneath 
Poupart's ligament on the outer side of the bloodvessels or burrowing still 
lower in the leg. When the arches are involved in the tuberculous pro- 
cess the abscess customarily points backward. In|its ultimate development 
caries not infrequently involves the cord and its nerves, producing in- 
flammatory and pressure symptoms, exceptionally incident to narrowing 
of the bony canal, usually due to pachymeningitis. 

Tuberculous spondylitis, obvious in its later course, is characterized 
in its early stages by pain, which may be persistent and of a throbbing 
character and exhibit severe exacerbations with radiations incident to jars 
or sudden motion, by rigidity of the affected part of the spine, and by the 
habitual assumption of such postures as tend to remove the weight of the 
body from the diseased area. jNIoreover, there are often night cries due 
to sudden spasmodic contraction, torticollis when the disease involves 
the upper cervical vertebrae, shallow, grunting respiration and irritative 
cough when the dorsal vertebrae are affected, and colicky pains in dorsal 
and dorsolumbar involvement. Particularly in the case of children there 
is a marked change in habits and disposition, cheerful activity being 
replaced by a condition of languor and querulousness. There is steady 
deterioration in general health, and the tuberculin reaction is positive. 

The diagnosis is strongly suggested by local tenderness and fixation 
of a child's spine after slight trauma, or in the absence of this, these 
symptoms persisting and growing worse. In the case of infants it is 
often not suspected until distinct deformity occurs, the general irritability, 
failure in health, crying on being lifted or moved, and tendency to keep 
the spine rigid being attributed to colic or any of a number of various 
causes. 

The examination for suspected tuberculous spondylitis is conducted by 
stripping the patient to the trochanters, or below. Standing with heels 
together, knees straight, and pelvis held by the examiner, the patient 
is directed to bend forward as far as possible; this motion will accentuate 
a beginning prominence of the spinous processes, will be limited, and 
will occasion pain. 

With the body straight and the pelvis still held, the patient is directed 
to look as far back as possible, first over one shoulder, then over the 
other. This motion will be limited usually in both directions; the 
approximate region of limitation may be further determined by fixing 
the shoulders and directing similar motion to be made with the head. 

The patient is told to pick a small object, such as a match, from the 



342 THE SPINAL COLUMN 

floor; the stooping is done at the thigh, knee, and ankle, the back being 
kept straight, and on rising there is a tendency to use the hands on the 
thighs as a help. 

The patient is placed in ventral decubitus, and, with the pelvis held 
down, the straight leg is lifted upward, this to test contraction of the 
psoas muscle. Along the line of the spinous processes light percussion 
is practised to elicit local tenderness. 

When the cases of tuberculous spondylitis present themselves for 
examination there is usually kyphosis and unmistakable spinal rigidity 
and tenderness, making the diagnosis obvious. In the early stages the 
symptoms which are most characteristic, and which may not be elicited 
without careful examination, are limitation of motion in the spine and 
slight tenderness on local manipulation and percussion. Torticollis, 
thigh flexion from psoas involvement, and referred pain may be early 
symptoms. 

In some cases of tuberculous spondylitis the onset is insidious, even 
the general health remaining apparently unaffected, and angular deformity 
is the first symptom which calls for an examination. 

To distinguish tuberculous spondylitis from chronic post-traumatic, 
or from syphilitic spondylitis, may in the beginning be quite impossible, 
except by means of a negative tuberculin test. The age incidence is 
helpful, since the tuberculous process is rare in the adult and frequent 
in little children. The reverse is the case in regard to the two other 
affections. 

Typhoid Spondylitis. — Typhoid spondylitis occurs late in the course of 
typhoid fever, or even after convalescence seems fully established. It is 
marked by the sudden onset, in the lower dorsal or lumbar region, of 
severe pain, both local and referred, aggravated beyond endurance by 
the slightest movement, associated at times with muscular spasm. Con- 
stitutional symptoms are slight or wanting. Paresis of the bladder and 
rectum have been noted. 

The diagnosis is based on the sudden or rapid development and per- 
sistence (weeks, months) of pain and rigidity following typhoid fever. 

Gonorrheal Spondylitis. — Gonorrheal spondylitis, a rare complication 
of gonococcal infection, in its symptomatology closely simulates typhoid 
spine. The diagnosis is based upon the presence of gonococcal infection, 
the sudden onset of pain, tenderness and fixation in the spine area, and 
the betterment which promptly follows the removal of an infecting focus. 

Chronic Traumatic Spondylitis.— This is an inflammatory condition which 
may be immediately sequent to spinal injury or may follow it by an 
interval of weeks or months. It is characterized by localized pain and 
tenderness about the seat of injury, the former greatly aggravated by 
motion often referred and crippling in intensity, by both voluntary and 
involuntary fixation of the back by muscular action, by the gradual 
(months) development of deformity, usually kyphosis, and by apparently 
causeless exacerbations or remissions. There is a softening process 
incident to inflammation, in turn probably kept up by inadequate treat- 
ment of an unsuspected fracture. 



TUMORS OF THE VERTEBR/E 343 

The distinction from early tuberculosis is in children impossible 
except there be obtained a negative tuberculin test. The early severe 
crippling pain in adults, who are less subject than children to Pott's 
disease, would suggest an osteitis of other than tuberculous origin. The 
absolute diagnosis even in them must be a matter of time, observation, 
and the results of the tuberculin test. 

Spondylitis Deformans. — Spondylitis deformans, or osteitis deformans, 
called also rheumatoid arthritis, is usually one of the local manifestations 
of a general trouble. It may, however, be confined entirely to the spine, 
and may begin in childhood. The affection is characterized by pain, 
tenderness, and gradual stiffening, requiring for its full development many 
years. The normal curvatures undergo gradual modification, and the 
spine exhibits but a single dorsal curve. The pain is subject to remis- 
sions. Root pressure may occasion severe referred paroxysms or may 
cause sensory or motor palsy. 

This affection not infrequently begins in the neck, travelling down- 
ward. The recognition of the well-developed disease offers no difficulty. 
In its incipiency, especially when it begins in childhood, the distinction 
from tuberculous spondylitis is difficult, and will in the main depend 
upon the results of the tuberculin test and prolonged observation. 

Syphilis. — Syphilis of the bodies of the vertebrae (rare) may appear in 
either the hereditary or acquired form of the disease. It may so closely 
simulate tuberculosis in its early development as to make a diagnosis 
impossible, excepting it be based upon a history of syphilis and associated 
evidence of this and the negative evidence of the tuberculin test. 

Actinomycosis. — Actinomycosis (rare) cannot be diagnosticated as such 
except by the finding of the ray fungus in the discharge and associated 
lesions elsewhere. 

Tumors of the Vertebrae. — Tumors of the vertebra are nearly 
always malignant and secondary. Carcinoma is the usual form and is 
frequently sequent to primary foci in the breast, uterus, or prostate. In 
metastasis from the prostate the spinal manifestations may precede 
the appearance of clinical signs indicating the original focus of infiltra- 
tion. As a rule, the body of but one vertebra is involved; this is 
commonly in the lower thoracic or lumbar region. 

Primary sarcoma is more frequently reported than primary carcinoma. 

Myeloma, extremely rare, characterized by a softening of the bone, 
resembles osteomalacia rather than tumor, from which it is distinguished 
by the failure of medicinal and hygienic therapeutics to accomplish 
betterment. 

Exostoses and cartilaginous overgrowths (rare) produce only pressure 
symptoms. They may mechanically interfere with motion. They are 
usually associated with similar outgrowths from other and more accessible 
bones. 

The diagnosis of tumor of the vertebra is based upon pressure symp- 
toms, at least in the early stage of the development of these growths. 
These are manifested in the form of pain located at the seat of infiltra- 
tion, radiating along the course of the involved nerves, and in the case of 



344 THE SPINAL COLUMN 

malignant growths becoming rapidly excruciating in type. The involved 
area is usually sensitive to deep palpation; ultimately deformity and at 
times tumor develop. Deformity in case of malignant growths is usually 
sudden and incident to slight trauma. 

In distinguishing from tuberculous infiltration, the age incidence, the 
steady progression of the affection, the failure of extension to relieve 
the pain, the evidences of both cord and root pressure, and particularly 
the discovery of a primary focus are of importance. Moreover, a tuber- 
culin test is likely to be helpful. 

An eroding aortic aneurysm will cause much the same symptoms as a 
cancerous infiltration, but is usually distinguished by other characteristic 
symptoms of this condition. 

The detection of benign tumors depends entirely upon their slow 
development and the persistence of symptoms of localized root or cord 
pressure or both. Pain is likely to be the dominant feature. When the 
growth is a bony one, the ir-rays will be helpful. 



CHAPTER XIY. 

THE UPPER EXTREMITY. 
THE HAND AND WRIST. 

The skin on the dorsum of the hand is comparatively thin, loosely 
attached, and there can be seen coursing beneath it a number of large 
veins. The palmar skin is thick, richly supplied with sweat glands, and 
closely attached to the deeper tissues by an abundance of connective- 
tissue bands running vertically downward. The sheaths of the flexor 
tendons extend from the base of the third phalanx to the level of the meta- 
carpophalangeal joints, with the exception of the flexor sheath of the 
little finger, which usually communicates directly with the common flexor 
bursa lying beneath and above the annular ligament. The sheath of 
the flexor longus pollicis also passes directly beneath the annular liga- 
ment and into the forearm. 

The knuckles of the closed fist are formed by the distal end of the 
metacarpals and the first row of the phalanges. 

On the palmar surface of the wrist to the radial side, and at a lower 
level than the styloid process, may be felt the tuberosity of the scaphoid, 
and immediately below this the ridge of the trapezium. To the ulnar 
side and about the same level may be felt the pisiform with the unciform 
more deeply placed and internal to it. The interphalangeal joints allow 
of flexion and extension. The metacarpophalangeal joints also of 
abduction and adduction when the fingers are extended. 

The radial and ulnar styloid processes are the prominent bony points 
about the wrist. A line joining the tips of the styloid processes does not 
form a right angle to the long axis of the forearm^ the radial process 
lying at a lower level (quarter to half an inch). 

The bony projection just proximal to the base of the third metacarpal 
bone, made prominent by flexion of the wrist, is the os magnum. 

To the outer side of the wrist in the depression bounded on the radial 
side by the tendons of the extensor ossis metacarpi pollicis, and extensor 
brevis pollicis, on the inner (ulnar) side by the extensor longus pollicis, lies 
the snuff box, a skin hollow made conspicuous by abduction and exten- 
sion of the thumb. 

In its depth the trapezium can be palpated. 

Though the metacarpals and phalanges are easily palpated, fractures 
of these bones may escape detection. 

The wrist joint allows of flexion until the long axis of the hand makes 
a right angle with that of the forearm, extension to a little more than 



346 



THE UPPER EXTREMITY 



half this degree, abduction (to the radial side) of 20 degrees, adduction 
of 45 degrees, with combinations of these movements. 

The thumb can be flexed and adducted until it touches the palmar 
base of the little finger and abducted to nearly a right angle with the 
long axis of the palm. 

The metacarpophalangeal joints, except that of the thumb, can be 
flexed to a right angle, the midphalangeal joint to beyond a right angle, 
the distal phalangeal joints to very near a right angle. 

The commonest lesion about the wrist is a sprain. Great swelling, 
severe pain, and pronounced or prolonged disability are presumptive 
evidence of more serious injury. 

Congenital Deformities. — Congenitally the digits may be absent, 
supernumerary, or fused. The hand may be absent, wanting in its parts, 
or clubbed in any direction. There may be contractures, usually 
expressed by flexion of the little finger, and often bilateral. Exceptionally 
at birth the hand may exhibit the thickening of myxedema, associated 
with the general conformation of this lesion. 

Acquired Deformities. — These are due to loss of parts from trau- 
matism or destructive ulceration, contraction of scars incident to the 
healing of extensive wounds or ulcers, atrophy, hypertrophy or distor- 
tion following chronic inflammation of the bones, joints, or soft parts, 
or injuries or diseases of the nerves or their centres. 

Fig. 126 




Bilateral Dupuylien's contractures. Flexion of fingers. Fibrous bands in palm adherent to 
skin. Fifteen years' duration. (Carnett.) 



Dupuytren's Contracture.— This occurs in men past forty, usually those 
who do hard work with their hands, which are therefore subjected to re- 
peated slight trauma, and is characterized by an induration, nodulation. 



THE HAND AND WRIST 



347 



thickening and shortening of the palmar fascia with intimate skin 
attachment. 

The tendon-Hke bands first fix the Httle finger in flexion, with subse- 
quent involvement of the other fingers, but not the thumb. This 
fixation and flexion is confined to the first and second joints. The con- 
dition is not attended by inflammatory symptoms. Distinction from 
fixation incident to muscular contracture is made by the superficial 
position of the bands, which are made obviously tense by efforts to 
extend, this tension being uninfluenced by flexion or extension of the 
wrist. 

Fig. 127 Fig. 128 





> 




on Deformity from paralysis of the median nerve (ape hand). 



Deformity of paralysis of the ulnar 
nerve (claw hand). 

The postural distortions 
of palsies of either cerebral 
apoplexy, poliomyelitis, dif- 
fuse sclerosis, or peripheral 
nerve lesions (trauma, pres- 
sure neuritis) are character- 
ized by associated symp- 
toms. (See section 
Nerves.) 

Wrist Drop. — Wrist drop incident to injury of the musculospiral nerve 
is characterized by inability to extend the hand or fingers, with possibly 
slight anesthesia on the dorsal surface of the thumb and index finger. 

Claw hand, in its typical development usually due to injury of the ulnar 
nerve, is characterized by extension of the first phalanges and a flexion 
of the second and third, with inability to materially change this position. 
The fingers can be neither adducted nor abducted. In the contractures 
incident to late ulnar palsy the intrinsic hand muscles are w^asted, useless, 
and give no electrical reaction, excepting those of the thenar eminence 
and the outer lumbricals. Ape hand due to median paralysis (rare as 



348 THE UPPER EXTREMITY 

an isolated lesion) is characterized by thenar atrophy and lack of power 
to flex the second digital phalanges. There is wasting of the thenar 
and hypothenar eminences. 

Ischemic contracture (Volkmann), caused by tight bandaging, to which 
children are especially sensitive, and usually observed in the forearm, 
is characterized by rigid flexion fixation of the fingers and hand. Its 
onset after the application of dressings is indicated by severe pain, 
followed in a few hours by tender induration and paralysis of the com- 
pressed muscles. Thereafter there is a transitory swelling (days) and a 
rapid atrophy and contracture. Embolism, thrombosis, or any cause 
cutting oft* the blood supply of the muscles may cause this same con- 
dition. 

Occupation paresis, due to overuse of muscle groups, often associated 
with repeated slight traumata, as from the handling of tools, is character- 
ized by progressive paresis and atrophy, and at times by moderate 
pain. The diagnosis is based upon the disability and atrophy of an over- 
used muscle group. 

Occupation spasm is characterized by incoordination of an overused 
muscle group associated with tendency to painful tonic spasm. Writer's 
cramp is a familiar example. 

Trigger Finger. — ^Trigger finger, or snapping finger, commonest in the 
middle finger of the right hand and in women (Weir), is evidenced by 
a sudden partial locking of the finger at one point, in either exten- 
sion or flexion, or both, followed by a sudden slightly painful release. 
It may be due to a localized swelling of the tendon, associated with an 
annular thickening of its sheath or to neoplasm. It is often traumatic 
in origin. 

Stunted useless fingers are often due to the destructive effects of 
syphilitic or tuberculous dactylitis of infancy. 

Repeated trauma of a joint is followed by permanent thickening and 
limitation of motion (baseball finger). A similar condition is noticed 
in the hand and finger-joints of laborers whose occupation compels long- 
continued or frequently repeated forced flexion of the hand. 

Deformities involving the joints of the fingers and hand due to the 
atrophic (common) or hypertrophic (rare) forms of arthritis deformans 
(see section on bones) may be trivial or extreme. The joints (multiple 
involvement, metacarpophalangeal and phalangeal) are enlarged, limited, 
in motion, and at times greatly distorted; there is marked muscular 
atrophy and a tendency to ulnar deflection of the hand (flipper hand). 
There is a suggestive history, the onset is slow (exceptionally acute), 
and the complete development of the deformity is a matter of years. 

Gouty deformity, which may be as pronounced as that from other 
forms of joint infection, is characterized in the beginning by acute attacks 
with complete remissions. Later by periarticular urate deposits (tophi). 

The thick broad hands of myxedema are associated with other and 
more marked symptoms of this condition. 

Pulmonary osteoarthropathy, in its hand development, is characterized 
by clubbing of the ends of the fingers. 



THE HAND AND WRIST 



349 



The deformity due to the destruction of the tissue of the fingers inci- 
dent to syringomyeha and the joint deformities of this condition are 
characterized by preservation of tactile sensation with loss of that 
incident to temperature and pain, and loss of function less pronounced 
than would seem proportionate to the extent of the lesion. This is 
also true of the joint affection of locomotor ataxia (rare). 

Acromegaly is characterized by a bilateral overgrowth of the hands 
and feet involving all the tissues, and associated with gigantism else- 
where, particularly in the lower jaw. 

Aside from enlargement of the epiphyses of the wrist, rickets does not 
produce marked deformity of the hand or fingers. Other and more 
characteristic signs are present elsewhere. 

Traumatic Affections of the Hand and Wrist.— Sprains.— Sprain 
of the fingers, hand, and wrist is characterized by tenderness and swell- 
ing in or around the joint, pain, and disability. 



Fig. 1291 



Fig. 130 





Fig. 129. — Fracture of base of metacarpal of thumb, separation of ulnar side of articular surface, 
and dislocation of metacarpal from trapezium, in male, aged forty-six years. (Frequent injury.) 
Clinical diagnosis of fracture not difficult, but proper reduction of both often difficult, especially 
when exact nature of injury is not recognized (when no x-ray is made). 

Fig. 130. — Common dislocation of thumb backward at metacarpophalangeal joint, in a female, 
aged twenty-five years. Clinical diagnosis easy, but x-rays important to exclude complicating 
fracture or show obstacles to reduction. 



1 Figs. 129 to 138. Fractures of the hand. Outline drawings from radiographs by Dr. H. K. Pan- 
coast in collection of University Hospital x-ray Laboratory; patients referred by or from services 
of Drs. Frazier, Wood, Musser, Siter, and Camett, from dispensaries, and private cases of Dr. 
Pancoast. 



350 



THE UPPER EXTREMITY 



Fig. 131 



Fig. 132 




Fig. 131. — Oblique fissured fracture of middle metacarpal, in male, aged twenty-three years. 
Clinical diagnosis uncertain, depending mainly on pain and local tenderness. 

Fig. 132. — Fracture of distal end of fifth metacarpal, in female, aged forty years. Displacement 
upward and to radial side. 



Fig. 133 




Oblique fracture of middle of shaft of fifth metacarpal; dislocation at fourth metacarpophalangeal 
joint, with separation of small fragment from epiphysis of fourth metacarpal. (Latter probably 
represents ligamentous attachment.) Boy, aged sixteen years. 



Fig. 134 



THE HAND AND WRIST 
Fig. 135 



351 



Fig. 136 



Fig. 134. — Oblique fissured fracture of proximal phalanx of fourth finger, in adult male. 

Fig. 135. — Fracture of base of proximal phalanx of fifth finger, with separation of half the articular 
surface, in adult female. Clinical diagnosis of such fractures often either difficult or not made, 
but recognition important on account of danger of subsequent disability if not properly treated. 

Fig. 136. — Fracture of base of proximal phalanx of index finger, w-ith separation of very small 
fragment from articular surface, in adult male. Clinical diagnosis difficult, but recognition just 
as important as in the preceding case, and for the same reason. 



Fig. 137 



Fig. 138 





Fig. 137. — Fracture of proximal end of middle phalanx of third finger, with separation of fragment 
of posterior portion of articular surface, in adult male. Baseball injury. Fracture shown in lateral 
view only (B), as is often the case in such injuries. (Two views should always be taken.) Clinical 
diagnosis difficult. 

Fig. 138. — Incomplete fracture of distal phalanx of thumb, in adult female. Only injm-y sustained 
in fall one story down elevator shaft. Clinical diagnosis of fracture not made. Shows in antero- 
posterior view (A) only, B, lateral view, and the one usually made in radiographing hand. 

Sprain of the last finger-joints is at times complicated by a tearing 
away of the attachment of either the extensor or flexor tendon, making 
it impossible to extend in one case (hammer finger), or to flex in the 
other (bayonet finger), the last digit. 



352 



THE UPPER EXTREMITY 



The loss of power is characteristic. Before sweUing has developed 
the small fragment of bone may be felt. The a;-rays are diagnostic. 

Sprain of the wrist is usually accompanied by tenosynovitis, this often 
being the major lesion, and, if severe and attended by great swelling and 
pain, may require the administration of ether or the use of the x-rays 
to exclude fracture or luxation. 

Tenosynovitis of the radial extensors is regarded as highly character- 
istic of fissured fracture of the radius. 

All sprains characterized by persistence of disability, pain, local 
tenderness, and swelling should suggest the probability of a complicating 
fracture, for the diagnosis of which the ic-rays are needful. 

Fractures of the Bones of the Fingers, Hand, and Wrist. — Fracture of the 
digits, usually due to direct violence, if complete, exhibits characteristic 
features. 

Chipping off of articular surfaces, usually regarded as simple sprain, 
has been shown by the a^-rays to be fairly common. Pronounced intra- 
articular effusion and continued pain and tenderness would suggest such 
an injury. The diagnosis must be made by the rr-rays. 



Fig. 1391 



Fig. 140 





Figs. 139 and 140. — Fracture of lower end of radius of unusual type, in which the outer Cradial) 
and palmar portion of the articular surface is split off. (In "Barton" type dorsal portion is sepa- 
rated.) Complicated by separation of styloid of ulna and fracture of scaphoid. Male, aged forty 
years. Fig. 139, anteroposterior view; Fig. 140, lateral view, showing displacement of lower 
radial fragment toward palmar aspect and upward. Exact clinical diagnosis difficult. 



1 Figs. 139 to 143. Complicated injuries in the region of the wrist. Outline drawings from 
radiographs by Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; patients 
referred from service of Dr. Siter, and from dispensaries. 



THE HAND AND WRIST 



353 



Fig. 141 



Fig. 142 





Fig. 141. — Complicated injury in wrist of sailor, aged twenty-two years, resulting from a fall 
into hold of vessel, comprising the following: Fracture of styloid of radius, displaced upward; 
scaphoid split into three pieces, 1A,1B,1 C; relative or actual subluxation of carpus and hand later- 
ally to radial side; lateral (ulnar) dislocation ot cuneiform, pisiform, and semilunar. Exact clinical 
diagnosis of injury practically impossible. 

Fig. 142. — Impacted and comminuted CoUes' fracture, with separation of tip of styloid of ulna, 
complicated by fracture of scaphoid and dislocation of pisiform, in adult female. Referred to 
hospital with clinical diagnosis of sprain of wrist, but possible fracture. Clinical diagnosis of none 
of the separate injuries easy, however. 

Fig. 143 




CoUes' fracture (above but extending into epiphyseal line), with separation of entire styloid of 
ulna, complicated by fracture of scaphoid, in a boy, aged fifteen years. (Latter fracture not 
determined clinically.) 

The tearing away of a fragment of bone from the base of the third 
phalanx by its tendinous attachment leaves a joint fixed in either exten- 
sion or flexion (bayonet finger, hammer finger). 

Fractures of the metacarpal bones, transverse if from direct violence, 
oblique, spiral, or fissured if from force applied to the^knuckles, may be 
23 



354 THE UPPER EXTREMITY 

obvious. They are, however, often attended by but sKght displacement, 
and can be recognized only by extreme and persistent localized tender- 
ness and swelling and later the formation of callus. The tenderness is 
elicited either by pressure at the seat of injury, or, the fingers being flexed, 
by suddenly pushing against the knuckle of the affected bone toward 
the wrist. 

Even the ir-rays may fail to show the fracture unless both antero- 
posterior and lateral exposures are made. 

An oblique fracture involving the articular surface of the metacarpal 
bone of the thumb, usually caused by a blow with the clenched fist, the 
impact falling upon the first phalanx of the thiunb, is rarely recognized 
as such, since the effusion into the joint, the general swelling, and the 
extreme tenderness make the elicitation of crepitus or mobility difficult 
or impossible. The deformity is strongly suggestive of backward luxa- 
tion of the metacarpus upon the trapezium. Since this injury is 
characterized in its ultimate development by considerable deformity, 
persistent disability, and much pain, its early diagnosis is important. 

This can be made best by the x-rays, though a deformity consisting of 
backward luxation of the first metacarpus, which is readily reduced but as 
easily recurs, is highly suggestive. Later a bony swelling on the outer 
side of the joint attended by limitation of motion, pain, and tenderness 
will sufficiently characterize the nature of the affection. 

Fractures of the carpal bones, usually due to indirect violence, as from 
striking a blow with the fist or a fall upon the hand, are attended by marked 
and rapid effusion into the joint, pain, and extreme local tenderness on 
deep palpation. These fractures are usually unrecognized, and are the 
common underlying lesions of persistent disability and gradually in- 
creasing deformity following injury which was supposed to have been 
sprain and was so treated. 

The scaphoid is the bone commonly broken. Codman notes as 
characteristic symptoms, localized tenderness in the anatomical snuff 
box when the hand is adducted, swelling on the radial side of the back 
of the wrist, and pronounced disability. These symptoms do not dis- 
appear, as in the case of sprain, but either persist or recur and are asso- 
ciated with limited motions of the wrist and hand and painful spasm on 
efforts to increase this motion, particularly if these be made in the direc- 
tion of extension. Carpal fracture may be complicated by other fracture 
or by luxation. 

Fractures of the Lower Extremity of the Radius. — Colles' fracture, the 
one usually encountered in the region of the wrist, is commonest in the 
middle aged as the result of a fall on the palm. The break is placed 
from one-half to one and one-half inches above the joint surface of 
the radius, and is generally slightly oblique. It may be impacted or 
slightly or extensively comminuted. The lower fragment is generally 
displaced backward and may be rotated in the same direction. There 
is at times a complicating luxation of the head of the ulna, this portion 
of the bone being displaced beneath the tendon of the extensor carpi 
ulnaris. The ulnar styloid is sometimes broken. 



THE HAND AND WRIST 

Fig. 144 



355 




Colles' fracture. (Anger.) 

The diagnosis is based upon obvious deformity (silver fork) and, in the 
absence of impaction, unnatural mobility and crepitus. When the 
fracture is impacted, the deformity is characterized by radial deflection 
of the hand and angular deformity which can be both seen and felt. The 
upper end of the lower fragment projects on the dorsal surface of the 
wrist above the articular line, the lower end of the upper fragment form- 
ing a similar projection on the palmar surface of the wrist. 

The radius is shortened, as shown by the elevation of its styloid to the 
level of that of the ulnar or even above this, and by measurements from 
the external humeral condyle to the radial styloid in the two arms. 
There is pain, swelling, and limitation of all motions. 

A fall upon the back of the flexed hand may produce a Colles' fracture, 
but with the deformity reversed, i. e., the lower fragment rides forward. 



Fig. 1451 



Fig. 146 





Fig. 145. — Old ununited (by bony union) fracture of scaphoid, in a male, aged nineteen years. 
Neither diagnosticated nor treated, x-ray examination made to discover cause of disability. 

Fig. 146. — Recent fracture of scaphoid, with separation of tip of styloid of ulna, in a male, aged 
twenty-six years. Clinical diagnosis difficult. 

1 Figs. 145 to 149. Uncomplicated fractures of the carpal bones. Outline drawings of radio- 
graphs by Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; patients 
referred from dispensaries, and pri^•ate cases of Dr. Pancoast. 



356 



THE UPPER EXTREMITY 

Fig. 147 




Fracture of cuneiform, in adult female. Not diagnosticated or treated. Radiograph made three 
weeks after injury to determine cause of disability. Clinical diagnosis yery difficult, however. 



Fig. 148 



Fig. 149 




Figs. 148 and 149. — Fracture of cuneiform and complete anteroposterior dislocation of semi- 
lunar in left wrist of male, aged twenty years. (Clinical diagnosis, CoUes' fracture.) Fig. 148, 
anteroposterior view of injured wrist; Fig. 149, same view of normal right wrist. Lateral view 
(omitted here) shows rotation of semilunar on lateral axis about 90 degrees, so that articular surface 
for the OS magnum faces directly toward the palmar aspect of the wrist. Pressure on median 
nerve. Exact diagnosis not only not made clinically, but would be extremely difficult or vpx-' 
possible in any case. Lateral view essential for x-ray diagnosis. 



THE HAND AND WRIST 



357 



the upper backward (gardener's spade deformity). When Colles' 
fracture is compHcated by avulsion fracture of the ulnar styloid, due to the 
pull of the internal lateral ligament, and this is usual when there is marked 
deformity, mobility, crepitus, and local tenderness make the diagnosis 
obvious. 

Fracture of the ulnar styloid may result from violent twisting of the 
wrist in the absence of radial fracture. The superficial position of the 
bony prominence makes the demonstration of characteristic symptoms 
easy. 

Fissured fractures of the lower extremity of the radius running into 
the joint, or fracture of the epiphyseal line or near it, may be without 
displacement, preternatural mobility, or demonstrable crepitus. 

A diagnosis of fissured fracture of the radius is suggested by bone 
tenderness on deep pressure and by effusion into the synovial sheaths 
of the extensor longus pollicis and radiocarpal extensor (Codman), 
characterized by the rapid development of a tender fluctuating swelling 
on the back of the wrist-joint, obscuring these tendons and projecting 
for a short distance upward over the dorsal aspect of the radius along 
their course. The positive assurance of the presence of buch a lesion 
can be secured onlv bv the x-ravs. 



Fig. 150 




Recurrent backward dislocation of (proximal phalanx of) thumb. Proximal phalanx hyper- 
extended, with its head resting on the dcrsal aspect of the metacarpal. Distal phalanx flexed. 
(Carnett.) 



Luxations of the Hand and Wrist.— Luxations of the phalanges are 
attended by the characteristic symptoms of gross and obvious deformity, 
fixation, and complete disability. If partial, these displacements may 
escape attention because of swelling and tenderness. 

Radiocarpal luxation (rare) forward or backward exhibits the defor- 
mity of Colles' fracture, except that the radial styloid maintains its proper 
relation to the ulnar and there is shortening of corresponding measure- 



358 THE UPPER EXTREMITY 

ments on the healthy and injured side as taken between the radial 
styloid and a bony point of the hand. This luxation may be complicated 
by Colles' fracture. 

Radio-ulnar luxation from violent twisting of the wrist is character- 
ized by prominence and mobility of the ulnar head. In some people 
this joint is naturally prominent and exceedingly movable. 

Luxation of the individual carpal bones affects usually the os magnum 
and the semilunar. The os magnum dislocated backward, often carry- 
ing the semilunar with it, sometimes with this bone completely reversed, 
forms a projection at the back of the wrist at the base of the third meta- 
carpal bone, easily recognized unless obscured by swelling and great 
tenderness. 

Fig. 151 




Metacarpophalangeal dislocation. 

The semilunar bone, if displaced forward, in addition to the pain and 
disability, makes the upper surface of the os magnum unduly prominent 
on the dorsum of the wrist. The deformity and disability are similar 
to those of Colles' fracture. The radial and ulnar styloid exhibit their 
normal relation to each other, and examination shows that the deformity 
is placed below the articular line and not above it. Swelling and 
tenderness may make the diagnosis of this injury impossible without an 
examination under ether or the use of the rc-rays. 

Subluxation of the wrist, noted in young working people whose occupa- 
tion requires constant use of the flexors of the arm, is characterized by a 
widening of the wrist, at times a forward bending of the lower extremity 
of the radius and dorsal prominence of the ulna. There is weakness, 
limited extension, and pain on use. This condition is due to irritation of 
the growing epiphysis. 

Acute Inflammatory Affections of the Soft Parts of the Hand and 
Wrist. — ^The acute dermatitis of rhus poisoning may occasion some 
diagnostic difficulty in the absence of a history of exposure. The free 
vesiculation, irregular distribution, and moderate constitutional symp- 
toms are characteristic as contrasted to erysipelas, which, when it attacks 
the hand complicates an obviously infected wound. 

Cellulitis. — Cellulitis (common), secondary to wounds which may be 
slight, is characterized by pronounced edematous swelling extending up 



THE BAND AND WRIST 359 

the arm, most marked on the back of the hand. It is often preceded by 
the red tender edematous streaks of lymphangitis, is accompanied by 
the constitutional symptoms of sepsis, and may be complicated or fol- 
lowed by suppurative inflammation of the epicondyloid or axillary 
glands. In exceptionally virulent infections the constitutional symp- 
toms may precede by some hours the local swelling. 

Furuncle. — Furuncle, or boil, usually on the dorsal aspect of the hand, 
wrist, or fingers, begins with a folliculitis, which is stimulated to further 
development by slight traumatism, usually that incident to the rubbing of 
a cuff or glove. It is distinguished from a poisoned wound by its history 
of onset, its slower course, and fairly sharp limitation. 

Paronychia. — Paronychia usually begins with heat, redness, and throb- 
bing pain, generally at the base of the nail, where there shortly forms a 
yellow bleb, from which, on puncture, one or two drops of pus are dis- 
charged. This inflammation may almost painlessly involve the entire 
nail base or may burrow wide of this beneath the epidermis (subcutic- 
ular), forming a pustule. Often it is the starting point of felon. 

Fig. 1.52 



Diffuse syphilitic paronychia. (Taylor.) 

Cellulitis of the Finger. — Here the pain is severe, throbbing, constant. 
The finger is swollen and excessively tender, there is accompanying 
lymphangitis and moderate fever. The cellular tissue of the finger is 
the portion first involved in the inflammation (subcutaneous); if the 
condition be unrelieved, the tendinous sheaths become infected; finally 
the bones (distal phalanx) and joints (midphalangeal). The swelling 
usually terminates, at least in its hyperacute form, before reaching the 
middle third of the palm. 

If the tendon sheaths of the thumb or little finger are affected, the 



360 



THE UPPER EXTREMITY 



infection more rapidly and surely reaches the wrist-joint and forearm 
beneath the deep flexors. 

The common cause of tendon sheath infection is environing cellulitis, 
particularly when the cause of this also produced a predisposing con- 
gestion of the tendinous sheaths, as in the case of those infected fingers 
which so frequently follow rowing or handling tools after a period of rest. 

The distinction between subcutaneous cellulitis and involvement of 
tendon sheaths, bone, or joint should be made by free incision and 
direct examination. 

Fig. 153 




Keratitis palmaris (arsenical). Shot-like nodules of epithelium embedded in the thick skin. 

(Hartzell.) 

Palmar Abscess. — Palmar abscess, usually secondary to digital cellu- 
litis, also caused by wound, sprain, or contusion, with blood effusion into 
and beneath the palmar fascia, is characterized by severe pain, fever, 
prostration, and swelling of the entire hand, which becomes like a pus- 
soaked sponge. Because of the dense tissues lying in the palm, the 
swelling aijd edema are usually more pronounced on the dorsal aspect. 

The infection travels up the wrist and into the cellular structures of 
the forearm. It may involve the wrist-joint in a suppurative arthritis, 
and commonly causes sloughing of the tendons. 

Chronic Inflammation of the Soft Parts of the Hand. — Erysipeloid.— 
Erysipeloid is an affection common to those who handle fish, oysters, 
and raw meat, characterized by a slowly spreading (weeks), dusky red 
inflammation of the skin of the hand, usually the fingers, exhibiting 
raised borders and all the features of an erysipelas, with the exception 
of the progression and the constitutional symptoms of the latter. Of 
the inflammatory skin lesions, psoriasis, keratitis palmaris, and derma- 
titis repens all from their obstinate persistence should be recognized 
on sight. 



THE HAND AND WRIST 



361 



Dermatitis vegetans (rare), without obvious cause^ is characterized by 
its slow course and persistence in the absence of antiseptic treatment. 



Fig. 154 




Dermatitis vegetans. (Hartzell.) 
Fig. 155 




Dermatitis repens. Slowly spreading (months), superficial, exfoliating dermatitis. (Hartzell.) 



362 THE UPPER EXTREMITY 

Traumatic Ulcers. — ^Traumatic ulcers, superficial, irregular in shape, 
indolent, but slightly indurated, exhibiting areas of healing and breaking 
down, and not painful, are such as are found on hands subject to repeated 
slight trauma without opportunity for cleanliness and protection. These 
lesions are observed on the hands of guides, masons, bricklayers, wood- 
choppers, etc. 

Syphilitic Ulcers. — Syphilitic ulcers may appear in the form of chancre, 
secondary or tertiary lesions. 

Chancre, often beginning in a hang-nail or an unobserved scratch or 
abrasion, appears as a chronic, slowly spreading, often painful, persistent 
ulcer, on any part of the fingers or hand, but commonly at the base 
of the nail. Often there is in the latter case an associated swelling of 

Fig. 156 




Palmar syphilide (late lesion). (Hartzell.) 

the entire phalanx. In appearance these ulcers do not resemble chancres 
seen on the genitalia; the surrounding induration is not sharply circum- 
scribed. 

The diagnosis must be based upon their persistence, the difficulty of 
explaining their presence on any other basis, the associated epitrochlear 
and axillary enlargement, and the finding of the spirochete. Usually 
it is not made until the secondary eruption develops. Physicians are 
peculiarly subject to such lesions. 

Chancre over the knuckles or back of the hand, usually secondary to a 
tooth wound, conforms more to the type of a venereal sore in that it is 
rounded or oval, indolent, persistent, and slow in progression. 

The inoculation of virulent sepsis and syphilis may occur at the same 
time, the cellulitis, lymphangitis, and lymphadenitis of the former 



THE HAND AND WRIST 



363 



completely masking the latter for weeks or months. Moreover, chronic 
sepsis exhibits at times skin manifestations not unlike those of secondary 
syphilis. A diagnosis under such circumstances must be made by the 
therapeutic test, by the development of typical lesions, and possibly by 
finding the spirochete. This mixed infection is exceedingly rare, is 
seen mainly in doctors infected during operation, and in them is fre- 
quently imaginary. 

Fig. 157 



^^ 



Dactylitis syphilitica. (Taylor.) 
Fig. 158 




Dactylitis syphilitica. (Taylor.) 

Secondary lesions of syphilis, usually non-ulcerating, commonly appear 
in the form of papular exfoliating palmar lesions. Associated symptoms 
make the diagnosis. 

Tertiary lesions are characterized by nodulations which exceptionally 
ulcerate and slowly extend in a circinate form. 

The diagnosis is based upon the indolence of the lesions, their circinate 
borders, and associated symptoms. 



364 THE UPPER EXTREMITY 

Circumscribed gumma involving the soft parts of the hand is rare. It 
corresponds in type to gummata in general. 

Ulcerating sinuses incident to the breaking down of a gummatous 
lesion of the phalanges of infants are common manifestations of heredi- 
tary syphilis. 

^ Deep^ trichophytosis may form a superficially ulcerating lesion, the 
diagnosis of which can be established only by the microscope. 





Fig. 


159 








■ 






P 


I 


■ 


w 






^^ 


^1 


^H 






WM 




^^ 4i« 


3 



Deep trichophytosis. (Hartzell.) 

Tuberculosis. — Tuberculosis of the soft parts of the hand and fingers 
is rare, if the chronic ulcerations and papillary outgrowth observed 
in the hands of those working in the dissecting room be excepted. 
These lesions appear either in the form of small clusters of warts, ulcerat- 
ing or pustulating at the base, or as nodular, indolent ulcerations. The 
diagnosis is based upon the finding of the tubercle bacillus. 

Lupus may assume any of its forms, i. e., hyperemic, verrucous, 
nodular, or superficially or deeply ulcerating. In the last type it is 
ultimately attended by deforming and crippling contracture. It begins 
in youth on the dorsal aspect, is extremely indolent (years), and is 
resistant to cleansing and protecting treatment. 

Tuberculous Tenosynovitis. — A chronic painless tenosynovitis is the 
commonest tuberculous lesion involving the soft parts of the hand. 
Indolent, fusiform, soft swellings form along the course of the tendons, 
sometimes the flexors of the fingers; usually the involvement is of the 
com mon flexor sheath. The palm is gradually (years) distended by a 
soft painless tumor, which also appears on the wrist. The communication 
of ^he swellings beneath the annular ligament is shown by fluctuation. 
Usually, because of the rice-like bodies with which the synovial sac 
is filled, there is, in addition to fluctuation, a chain-like grating on 



THE HAND AND WRIST 365 

manipulation. There is muscular atrophy and limitation of flexion, or, 
when the tendons themselves are fibrillated and destroyed, complete loss 
of motion. Involvement of the sheath of the extensors is manifested 
by a globular swelling on the back of the wrist-joint. In the fun- 
gating form of tuberculous tenosynovitis, softening and sinus formation 
occur. The seat of the swelling, its indolence, fluctuation, extent, 
and chain-like grating when this is present suggest the diagnosis of a 
condition which is not accounted for on any other than a tuberculous 
basis. 

Gonorrheal tenosynovitis is more acute in onset and subsidence. 
Lipoma of the palm may cause an enlargement exactly simulating teno- 
synovitis of the flexor sheath. It gives no crepitation and does not 
cause muscular atrophy or fixation to the same degree. The diagnosis 
is usually made by operation. 

Epitheliomatous Ulcers. — Epitheliomatous ulcers, found on the dorsal 
surface of the hands and fingers, usually begin in warts or cicatrices, and 
are characterized by the persistence of ulceration and slow extension. 
Later, the indurated, destructive, often fungating ulcer with glandular 
involvement is unmistakable. The chancre is more rapid in evolution 
(weeks), the gumma begins as a dermal or subdermal induration which 
softens and breaks down (weeks or months). 

Early diagnosis can be made only by microscopic examination of the 
excised lesion. 

Trophic Ulcers. — Trophic ulcers, incident to nerve lesion, are accom- 
panied by the changes in circulation and nutrition characteristic of the 
underlying lesion. These ulcers are persistent, painless, and progressive. 

Digital cellulitis, dependent upon syringomyelia, is highly destructive. 
There is usually fever, but aside from this the constitutional symptoms 
are slight. 

The diagnosis in the case of syringomyelia is based upon the preserva- 
tion of tactile sensation and the loss of sensation for temperature and pain. 

Gangrenous Affections of the Hand. — Acute traumatic gangrene 
following extensive injury exhibits the forms and symptoms of the 
affection as observed in other parts of the body (p. 99). 

Carbolic Acid Gangrene .^ — Carbolic acid gangrene, which may follow 
the continued application of a weak solution (1 to 100), is characterized 
by a numb, white area, becoming completely anesthetic, cold, black, 
and gangrenous. 

Diabetic Gangrene. — Diabetic gangrene, characterized by the rapid or 
slowly progressive sloughing of tissues out of proportion to the original 
trauma or infection, is suggested by this very fact and corroborated 
by urinary examination. 

Arteriosclerotic, or senile, gangrene, an affection of old age, which may 
occur in younger people, exhibits the prodromal symptoms of tingling 
pain, loss of heat, and impaired strength and motility, followed by 
vesiculation of the skin and dry gangrene. 

Symmetrical gangrene, or Raynaud's disease, is characterized by 
extreme pallor, coldness of the part, attended by blunting of sensation, 



366 THE UPPER EXTREMITY 

succeeded in turn by duskiness, bleb formation, anesthesia, and com- 
plete or partial local death. It is usually bilateral and involves more 
than one finger of each side. 

Embolic Gangrene.— Embolic gangrene, characterized by sudden 
onset, without previous pronounced symptoms, in the presence of a 
valvular heart lesion, is marked by the sudden circulatory failure, 
followed by typical symptoms of death of the part. The seat of arterial 
obstruction can usually be determined by palpation of the brachial 
artery. 

Inflammatory Affections of the Bones and Joints of the Hand 
and Wrist. — Acute inflammatory affections of the bones and joints of 
the hand and wrist, in their suppurative form, are nearly always second- 
ary to cellulitis and suppurative tenosynovitis. 

Acute post-traumatic, non-suppurative inflammation of the bones 
and joints, characterized by persistent pain and tenderness on deep 
pressure, swelling, usually obscured by exudate into the surrounding 
soft parts, and fixation of the joint in the position which allows of great- 
est distention of its capsule (slight flexion), is usually suggestive of 
fracture, for the detection of which the a:-rays are needful. 

Acute Gouty Periarthritis. — Acute periarthritis of gout closely simu- 
lates infection, but is characterized by an absence of history of trauma, 
sudden onset, swelling, heat and redness, and the absence of either 
lymphangitis or pronounced constitutional symptoms of septic absorp- 
tion. Tophi, when present, are diagnostic. 

Gonorrheal Arthritis. — Gonorrheal arthritis is characterized by acute 
inflammatory symptoms, joint fixation, severe pain, usually marked 
periarticular heat, redness, and swelling. The finger-joints and that 
of the wrist are especially subject to this involvement. It is usually 
complicated by tenosynovitis. 

The diagnosis is based upon the sudden onset of joint inflammation, 
for which no other cause than gonorrheal infection can be found. 

Acute Rheumatoid Arthritis. — This is distinguished from rheumatic 
arthritis only by the persistence of the joint lesions (polyarticular and 
bilateral), usually periarticular, with ultimate pronounced limitation of 
motion, distortion, and deformity, best marked in the midphalangeal 
and metacarpophalangeal joints. The affection develops in the young 
with fever, tt is usually called rheumatic. The functional prognosis 
is bad. 

Chronic inflammation of the bones and joints of the hand and wrist 
may be due to repeated slight trauma, infection of unknown origin 
(rheumatoid arthritis), tuberculosis, syphilis, or syringomyelia. 

Chronic Traumatic Arthritis.- — Chronic inflammation incident to re- 
peated slight trauma, exhibited most frequently in the wrist-joint, but 
possible in any of the articulations of the hand, is characterized by a 
gradual thickening and enlargement both of bone and periarticular 
tissue, producing deformity and disability. It is observed in young 
people who are compelled to use their hands constantly without oppor- 
tunity for rest, or in those who are subjected to slight injury, and who 



( 



THE HAND AND WRIST 



367 



have no opportunity for complete recovery from the same. In its early 
course it resembles tuberculous involvement, nor can it be distinguished 
from this except in its progress, there being no tendency toward soften- 
ing nor abscess formation. 

Tuberculous Arthritis. — Tuberculous arthritis often follows slight 
traumatism. It is observed in the wrist of the adult; in the metacarpo- 
phalangeal articulations in children. 

In the early stages of tuberculous arthritis of the wrist, pain, aggra- 
vated by use, partial fixation, muscular atrophy, and often a point of 
tenderness on deep pressure, are the symptoms. The wrist, hand, and 
fingers are held slightly flexed. 

A distinction from the continued disability, tenderness, and swelling, 
following fissured fracture, can be made only by the a;-rays, and by the 
fact that tuberculosis follows slight rather than severe trauma. 

Tuberculous arthritis is distinguished from arthritis produced by 
overuse only by the history and the result of brief rest in the latter case. 

Since, preceding a general joint invasion, the tuberculous process is 
often limited to the radial epiphysis, the base of the metacarpus or the 
carpus, an early diagnosis of such localization, suggested by local tender- 
ness, made possible often by the a--rays, is highly desirable. The slow 
(months) progression of the tuberculous process, forming a spindle- 
shaped swelling accentuated by muscular atrophy, involving the ten- 
dons and their sheaths and fixing them, and ultimately softening and 
discharging through fistulse which lead to carious bone, is characteristic. 



Fig. 160 




Tuberculosis of wrist and carpal joints, with suppurating sinus on dorsum of hand. Eighteen 
months' duration. Doughy infiltration of soft tissues. Grating of articular surfaces on manipula- 
tion. Motion limited in all directions. Similar lesion in knee-joint. (Carnett.) 



Tuberculosis of the metacarpals and phalanges, called spina ventosa, 
and usually an affection of childhood, is characterized by a painless, 
cylindrical swelling, at first of the bone, later involving the joint. It is 
followed (weeks or months) by redness and edema of the overlying skin, 
softening, and discharge of a curdy pus from sinuses which lead to 
dead bone. It results in pronounced deformity of the fingers and bony 
ankylosis. Recovery may take place without suppuration. 

Syphilitic Inflammation. — Syphilitic inflammation of the bones and 
joints of the hand presents a picture so like that of a tuberculous 
involvement that the differential diagnosis from the appearance alone 
is impossible. Associated symptoms and signs of syphilis and the 



368 



THE UPPER EXTREMITY 

Fig. 161 




Angioma, probably with lipomatous and fibromatous admixture. Dense, hard in place, unattached 
to the underlying skin, and movable on the bone below. Varying in size in accordance with the 
amount of local venous congestion. 



Fig. 162 



/prr:-^^ 




Traumatic epithelial cyst, usually be- 
neath the skin, which is not adherent. 
Vary from size of pea to that of walnut; 
contents similar to that in sebaceous 
cyst; may follow trauma by many years. 
(Berger.) 



therapeutic test furnish the means of 
differentiation. This test is futile when 
fistulse have formed. 

As in the case of tuberculosis, anky- 
losis or marked atrophy or distortion of 
the finger may result in the absence of 
suppuration. 

Tumors of the Hand and Wrist. 
— Multiple Angiomata. — Multiple angio- 
mata, either capillary or venous, are 
not infrequently seen on the back of 
the hand. Lipoma, fibroma, and seba- 
ceous cysts are rare. 

Epithelial Cysts. — Epithelial cysts, ob- 
served on the palmar surface of the 
finger, exceptionally the palm, form 
small, hard, rounded, non-inflammatory 
skin tumors, slow in growth. 

The diagnosis is based upon excision 
and microscopic examination. Neu- 
roma and neurofibroma of traumatic 
origin, forming about small encysted 
foreign bodies, are occasionally found. 
The diagnosis must be by the micro- 
scope. 

Ganglion. — Ganglion forms a rounded 
elastic tumor, the prominence and 



THE HAND AND WRIST 



369 



tension of which can be markedly altered by flexion and extension 
of the joint near which it occurs. Its appearance often follows slight 
traumatism or overuse, and its usual position is on the back of the wrist, 
to the ulnar side of the extensor carpi radialis, where it causes little 
discomfort aside from the deformity. When placed in front of the 
wrist, the pressure on nerves may cause distressing pain and disability. 
Exceptionally, these tense, rounded tumors, are found on the palmar 
surface of the metacarpophalangeal joints. 

The diagnosis is based upon the position of the tumor, its non-inflam- 
matory character, its slight mobility, its pronounced change in tension 
dependent upon joint position, and finally, upon excision. The contents 
are usually jelly-like and, though the cysts are adherent to the sheath 
of the tendons, they usually originate from the capsule of the joint itself. 

Fig. 163 




Multiple enchoudroma of the left hand, (v, Bruns.) 



Multiple Enchondromata. — IMultiple enchondromata form hard, pain- 
less tumors which are fixed to the bone and grow slowly (years). Sar- 
comatous degeneration is characterized by rapidity of growth and 
early metastases. 

Sarcoma. — Sarcoma of the melanotic variety may start in a nevus, 
particularly about the ungual region. It is usually of the spindle-cell 
variety, occurs in young people, and is characterized by rapid growth 
and the obliteration of the surrounding bone. 

Fibrosarcoma. — Fibrosarcoma forms a tumor, usually on the palmar 

surface of the fingers, attached to the flexor sheaths and attended by 

no symptom other than the inconvenience caused by this growth. It 

may remain (years) long standing and local, closely simulating a fibrous 

24 



370 



THE UPPER EXTREMITY 



thickening. Rapid growth of such an apparent thickening should 
suggest possible malignancy. The diagnosis should be based upon 
excision and microscopic examination. 

Epithelioma. — ^Epithelioma, originating in an ulcer, cicatrix, or wart, 
is marked by a persistent, slowly (weeks or months) spreading, 
destructive ulcer. The diagnosis is made by microscopic examina- 
tion. It is most malignant when it originates in congenital warts 
(Volkmann). 

THE FOREARM. 

Malformations are obvious. The forearm may be absent or the bones 
may only partially develop. The radius is more frequently involved 
than the ulna. 

Fig. 164 



Brachioradialis (supinator longus). 



Radial artery. 



Prominence of short extensor ten- 
dons of the thumb. 



Thenar eminence. 




Internal condyle. 
Brachial artery. 
Biceps tendon. 

Prominence of flexor and pronator 
muscles. 



Pronator radii teres m. 



Flexor sublimis digitorum m. 



Flexor carpi ulnaris m, 



Ulnar artery. 

Palmaris longus tendon. 

Median nerve. 

Flexor carpi radialis m. 

Line indicating wrist-Joint. 

Joint bet. 1st and 2d row carp, bones. 

Pisiform bone. 



Deep palmar arch 
Hypothenar eminence. 

Superficial palmar arch. 

Palmar digital arteries and nerves. 



Surface anatomy of the forearm. (G. G. Davis.) 



THE FOREARM 



371 



Traumatism. — The effects of traumatism may be manifested by con- 
tusion, subcutaneous rupture of muscle or tendons, wounds, fracture, or 
luxation. 

Subcutaneous rupture of tendons or muscles, usually the result of mus- 
cular action, is characterized by sudden, sharp pain, disability in so far 
as the muscle or tendon affected is concerned, localized tenderness and 

Fig. 165 



Triceps m. 



Olecranon process, 



Subcutaneous surface of the ulna. 



Styloid process of the ulna. 




External condyle. 
Depression for head of radius. 



Prominence formed by the extensor 
and supinator muscles. 



Posterior radial tubercle, marking 

the middle of the radius. 
Styloid process of the radius. 

Anatomical snuflf box. 



Surface anatomy of the forearm. (G. G. Davis.) 



swelling, and, if the rupture be extensive and superficial in the case of 
the muscle, or complete in the case of the tendon, the almost immediate 
formation of a soft tumor, deep pressure into which shows a break in 
continuity, increased by muscular contraction. 

Acute Tenosynovitis. — ^Acute tenosynovitis is a common expression 
of overuse occurring frequently in masons, carpenters, oarsmen, or 



372 



THE UPPER EXTREMITY 



washerwomen, who take up their work after a period of rest. It is 
characterized by tenderness and crepitation along the course of the 
tendons, particularly the radiocarpal and the thumb extensors. There 
is pain on motion and often slight redness of the overlying skin. Crep- 
itation is best detected by grasping the forearm just above the wrist 
and causing the patient to repeatedly flex and extend the hand and 
thumb. 



Fig. 1661 



Fig. 167 






(^ 






Figs. 166 and 167. — Fracture of radius near lower end, in a girl, aged ten years, resulting from 
fall on hand while roller skating. Anteroposterior view. Fig. 166, shows no deformity; lateral, 
Fig. 167, shows angular deformity toward palmar aspect, degree of which was not determinable 
clinically. (Important in female.) Clinical diagnosis of fracture easy.) 



1 Figs. 166 to 192. Fractures of the lower ends of the bones of the forearm. Outline drawings 
from radiographs by Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; 
patients referred by or from services of Drs. Wood, Carnett, and Siter, from dispensaries,'_and 
private cases of Dr. Pancoast. 



THE FOREARM 



373 



Fig. 168 



Fig. 169 





Fig, 168. — Fracture of radius, lower end, just above epiphyseal line, in a boy, aged seventeen 
years, resulting from fall on hand while roller skating. Anteroposterior view. (No displace- 
ment shown in either view.) This type corresponds to the Colles fracture in the adult, being 
usually a little higher than level of latter. Epiphyseal separations and fractures just above the 
line (of Colles) are less frequent. Clinical diagnosis not difficult, although fracture was more or 
less impacted. 

Fig. 169. — Typical example of impacted Colles' fracture, in adult male. No displacement in 
either direction; mobility and crepitus absent. Clinical diagnosis depends upon history of injury, 
pain, local tenderness, and swelling. Anteroposterior view. 



Fig. 170 



Fig. 171 





Figs. 170 and 171.— Typical example of so-called "Barton" fracture— splitting off of posterior 
portion of articular surface. Adult male, with chronic atrophic arthritis of wrist. (Note close 
approximation of carpal bones due to loss of cartilage.) Fracture shows in lateral view only, as 
IS often the case (Fig. 171). No deformity, but diagnosis of fracture not difficult clinically. 



374 



THE UPPER EXTREMITY 

Fig. 172 




Unusual type of fracture, in adult male. Radiograph two weeks after injury. Resembles 
"Barton" type more than "Colles." Considerable comminution at articular surface. Clinical 
diagnosis of fracture not diflScult, but x-ray important in proper reduction. Anteroposterior 
view. 



Fig. 173 



Fig. 174 





Fig. 173. ^Typical example of the common "automobile fracture," in an adult male. (Direct 
violence from back kick of crank.) A fissured fracture through the base of styloid process of radius. 
Clinical diagnosis often difficult, depending mainly on history, pain, and local tenderness. Fre- 
quently overlooked. Anteroposterior view. 

Fig. 174. — Colles' fracture, with comminution into joint, in an adult female. Also separation 
of tip of styloid of ulna, which x-rays have shown occurs in at least half these fractures, especially 
in falls backward on hand, as when slipping on ice. Anteroposterior view after reduction; good 
apposition. 



THE FOREARM 375 

Fig. 175 Fig. 176 





Figs. 175 and 176. — Epiphyseal separation lower end radius, in a boy, aged eleven years. Small 
fragment of diaphysis separated from posterior and outer edge with epiphysis. Anteroposterior 
view, Fig. 175, indicates no deformity laterally, but lateral view. Fig. 176, shows dorsal displace- 
ment of radial epiphysis, needing correction. Clinical diagnosis not diflBcult, especially when 
such displacement exists. (Without latter, x-rays always negative unless fracture accompanies 
epiphyseal injury.) 



Fig. 177 



Fig. 178 





Figs. 177 and 178. — Epiphyseal separation radius, with more extensive fracture of diaphysis than 
preceding, in a girl, aged thirteen years. Line of fracture starts posteriorly about level of Colles', 
then runs downward and forward into epiphyseal line, whence break continues as separation of 
epiphysis. Anteroposterior view, Fig. 177, indicates no lateral displacement, but also no certain 
evidence of radial injury. It does show a fracture through ulnar epiphysis at base of styloid. 
Lateral view, Fig. 178, shows dorsal displacement of epiphysis and fragment of diaphysis of radius. 
No difficulty about clinical diagnosis. 



376 THE UPPER EXTREMITY 

Fig. 179 ■ Fig. 180 





Fig. 179. — Colles' fracture at higher level than usual, and lower fragment comminuted into 
joint, accompanied by separation of both base and tip of styloid of ulna, in an adult female. 
Anteroposterior view after reduction. Clinical diagnosis of fracture not difficult, but x-rays im- 
portant in reduction. 

Fig. 180. — Comminuted Colles' fracture, rather high level and oblique in^ direction, with separa- 
tion of styloid of ulna, in an adult male. Joint not involved. Anteroposterior view after reduc- 
tion. Clinical diagnosis not difficult. X-rays made to determine apposition of fragments. 



Fig. 181 



Fig. 182 





i 



Figs. 181 and 182. — Comminuted Colles' fracture and separation of styloid of ulna, in an adult 
male. Anteroposterior view. Fig. 182, shows lateral displacement to radial side. (Note altered 
relation in levels of styloids of two bones.) Lateral view, Fig. 181, shows dorsal and upward 
displacement of lower fragment. No difficulty in clinical diagnosis of fracture, but x-rays important 
to show deformities requiring correction. 



THE FOREARM 



377 



Fig. 183 



Fig. 184 





Fig. 183. — Fracture of lower end of radius, differing from preceding Colles' types in direction of 
line. Accompanied by wide separation of styloid of ulna. Male, aged twenty-six years. Antero- 
posterior view, shows marked displacement to radial side, and shortening. 

Fig. 184.— Comminuted Colles' fracture, with separation of styloid of ulna in two fragments, 
in a male, aged thirty-three years. Fragments of comminuted lower main fragment driven apart 
by entering wedge of shaft, with widening of joint. Anteroposterior view. Clinical diagnosis of 
fracture easy, but a:-ray very important to determine nature of injury and deformity. 



Fig. 185 



Fig. 186 



Fig. 187 




Fig, 185. — Comminuted Colles' fracture (into joint) with fracture through neck of ulna, in adult 
female. Anteroposterior view shows good apposition after reduction. (Lateral shows persistence 
of dorsal displacement lower radial fragment.) Clinical diagnosis easy, object of x-rays to deter- 
mine result of reduction. 

Figs. 186 and 187. — Fracture radius (above level of Colles') and neck of ulna, in a boy, aged seven 
years. (More common level for radial fractures in children than lower down as in adults.) Antero- 
posterior view. Fig. 186 (before reduction), shows radial fragments in good position apparently, 
but head of ulna displaced upward and to ulnar side. Lateral view, Fig. 187, shows angular defor- 
mity in radius (toward palmar aspect) and bad displacement of ulnar head backward and upward. 
Clinical diagnosis of fracture not diflBcult, but z-rays important to reveal deformities. 



378 



THE UPPER EXTREMITY 

Fig. 188 Fig. 189 




Figs. 188 and 189. — Fracture of both bones of forearm in lower portions of shafts, in a boy, aged 
fourteen years. (Transverse and same level.) Very common type of fracture in children. Tip 
of styloid of ulna separated in addition. Anteroposterior view, Fig. 188, indicates slight lateral 
displacement both lower fragments to ulnar side. Lateral view. Fig. 189, shows complete dorsal 
displacement both lower fragments, with over-riding. Clinical diagnosis of fracture easy, but im- 
portance of a;-rays obvious. 



Fig. 190 



Fig. 191 





Figs. 190 and 191. — Fracture both bones lower portions of shafts, in a boy, aged fourteen years. 
(Transverse and same level; radius compound.) Anteroposterior view, Fig. 190, shows lateral 
displacement of both lower fragments to radial side. Lateral view. Fig. 191, shows displacement 
of both toward palmar aspect, complete in radius. (Exactly opposite displacements from preced- 
ing case.) 



THE FOREARM 

Fig. 192 



379 




Old fracture of both bones, similar in type to the two preceding cases, in a male, aged twenty- 
four years. Radius vmited in bad position; ulna ununited, lower fragment completely displaced 
laterally to ulnar side. Anteroposterior view. (Lateral view shows dorsal displacement of both 
lower fragments.) 

Fissured fracture of the lower extremity of the radius is attended 
by a tenosynovitis similarly placed but not giving crepitation because 
of a more abundant effusion. 

Wounds of the Forearm. — Wounds of the forearm call for determina- 
tion of cutaneous sensibility and power of free motion in the hand and 
wrist. 

Injury of the median nerve just above the wrist, usually associated 
with division of the flexor sublimis and palmaris longus, causes a sen- 
sory palsy of the palmar surface of the thumb, index and middle fingers, 
and radial side of the ring finger. Wounds higher up paralyze flexion 
at the second joints of all the fingers and the terminal joints of the 
index and middle fingers. If the wound be near the elbow, the power 
of pronation is lost. 

Injury of the ulnar nerve paralyzes flexion of the ring and middle 
fingers, adduction of the thumb, and abduction of all the fingers; also 
flexion of the first joint and extension of the other joints. There is 
anesthesia of the ulnar side of the hand, of the little finger, and the 
ulnar border of the ring finger. 

Injury of the posterior interosseous nerve is characterized by par- 
alysis of the extensor muscles, resulting in wrist drop, more or less 
complete in proportion to the height of the injury. 

Fractures of the Forearm. — Colles' fracture, the commonest injury, 
is discussed under affections of the hand and wrist. Fractures of 
the head and neck of the radius, of the olecranon, and of the coracoid 



380 



THE UPPER EXTREMITY 



process are considered in the section dealing with surgical affections 
of the region of the elbow. 

Fracture of both hones of the forearm, in children often of the incom- 
plete or green-stick variety, is usually placed below the middle, and is 
due to a fall upon the hand. The usual cause of complete fracture of 
both bones is direct violence. The break in both bones is at or near 
the same level. 

The symptoms in the case of green-stick fracture are obvious deformity, 
sharply localized tenderness and pain; in children there is sometimes 
surprisingly slight disability. 

The complete fracture is characterized by crepitus, preternatural 
mobility and deformity. Non-union is an occasional sequel. 

Fracture of the ulna, if occurring alone, is usually due to direct force. 
A break in the upper third of the bone is not an uncommon compli- 
cation of luxation of the radius. Because of its subcutaneous posi- 
tion throughout, fracture of the ulna is readily detected by palpation. 

Fractures of the shaft of the radius are usually in the middle third, 



Fig. 1931 



Fig. 194 





Figs. 193 and 194. — Fracture of both bones in upper third of shafts, in a child, aged five years, 
result of fall on hand. Radiographs three weeks after injury show union well advanced, with con- 
siderable angular deformity in ulna laterally to radial side. Injury neither diagnosticated nor 
treated as a fracture, although typical signs must have been present. Fig. 193, anteroposterior 
view at elbow; Fig. 194, lateral. 



1 Figs. 193 to 211.— Fractures of the shafts of both bones of the forearm. Outline drawings 
from radiographs by Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; 
patients referred by or from services of Drs. White, Wood, and Frazier, from dispensaries, and 
private cases of Dr. Pancoast. 



THE FOREARM 



381 



FtG. 195 



Fig, 196 





Fig. 195. — Fracture of both bones near junction of upper and middle thirds of shafts, in male, 
aged twenty years, result of fall from horizontal bar in gymnasium. Lateral view (at elbow, 
pronation) before reduction, shows angular deformity and complete lateral and forward displace- 
ment of upper ulnar fragment with over-riding. Clinical diagnosis not difficult. 

Fig. 196. — Fracture of both bones at junction of upper and middle thirds of shafts, in female, 
aged thirty-seven years, transverse, same level. Anteroposterior view before reduction shows 
complete lateral displacement with over-riding. 



382 THE UPPER EXTREMITY 

Fig. 197 Fig. 198 




Fig. 197. — Lateral view of case shown in Fig. 196, after fluoroscopic reduction. (Fore and aft 
also shows perfect reduction.) 

Fig. 198.— Same view of same case six weeks later, showing delayed but moderately firm union 
with marked angular deformity, for which the dressing, an anterior rectangular splint, may have 
been wholly or in part responsible. An illustration of the advisability of a;-ray examinations during 
treatment of some fractures to determine proper maintenance of reduction. 



and result from direct or indirect violence. The fracture is usually 
transverse or slightly oblique. It may be spiral. Its detection is 
based upon the classical symptoms, the local swelling and tenderness, 
and the failure of the radial head to rotate when the hand is alternately 
pronated and supinated. 

Inflammatory Affections of the Forearm. — Lymphangitis of the 
forearm, expressed in the form of a rose-colored, slightly raised band 
passing upward to the elbow along the course of the lymphatics, is 
symptomatic of infection of the hand. 

Cellulitis. — Cellulitis is secondary to trauma or is an upward exten- 
sion of palmar abscess. The pus is found not only in the superficial 
and subaponeurotic tissue, but when it travels along the tendon sheaths 
accumulates beneath the deep flexors. 



THE FOREARM 

Fig. 199 Fig. 200 Fig, 201 



383 



Fig. 202 



a 




Figs. 199 and 200. — Fracture of both bones about middle of shafts, in a yoiing boy. Clinical 
diagnosis of fracture not difficult, but examination made ten days after injury to determine 
position of fragments. Fig. 199, anteroposterior view, shows central displacement with complete 
obliteration of interosseous space. Lateral view. Fig. 200, indicates palmar and dorsal displace- 
ment of lower fragments in addition. Examination made barely in time to anticipate callus 
formation. 

Fig. 201. — Fracture of both bones at junction of middle and upper thirds, in a boy, aged 
thirteen years; vdna slightly comminuted and radius "subperiosteal" and nearly "green-stick." 
Detaclunent of styloid process of ulna. Injury resulted from a fall. Clinical diagnosis not diffi- 
cult, although radial fracture might escape notice. Anteroposterior view. 

Fig. 202. — Fracture in a girl, aged ten years; radius at junction of upper and middle thirds 
and "subperiosteal;" ulna lower and middle thirds and "green-stick." Anteroposterior view. 
Clinical diagnosis somewhat difficult, especially of ulnar fracture. 

Osteomyelitis .^ — Osteomyelitis (rare) is attended with the characteristic 
intense pain, total disability, and pronounced local and general symp- 
toms of pus formation and septic absorption. 

Syphilis. — ^The chronic ulcerative lesions of syphilis are not infrequently 
found on the skin of the forearm, and chancre has been observed here 
sufficiently often to make it a diagnostic possibility in the presence of 
a superficial indolent ulceration without obvious cause, which in the 
course of two or three weeks reaches the size of a half-dollar, and which 



384 



THE UPPER EXTREMITY 
FtG. 203 Fig. 204 





Fig. 203. — Fracture of both bones in middle third of shafts, in a boy, aged fifteen years; radius 
at higher level. Anteroposterior view, before reduction, shows complete lateral displacement of 
ulna and almost complete of radius, to radial side. Clinical diagnosis not difficult. (Lateral view 
shows no deformity.) 

Fig. 204. — Typical example of "green-stick" fracture of both bones, at middle of shafts, in a 
child, aged three years. Clinical diagnosis difficult. Anteroposterior view; no deformity. 

is attended with characteristic glandular enlargement. The early diag- 
nosis is based upon the findings of the spirochete. 

Tuberculous and syphilitic involvement of the muscles and bones 
of the forearm do not depart from type. Gumma of the ulna is 
fairly frequent, appearing as a palpable, moderately sensitive node. The 
diagnosis is based upon the history and the result of treatment. 

Tumors of the Forearm. — Lipoma may be either subcutaneous or 
subaponeurotic. In the latter case it may extensively infiltrate the 
cellular spaces between the muscles. The slow growth (years) and 
soft, almost fluctuating, consistency are characteristic. 

Neurofibromata and angiomata are fairly common on the forearm, 
and enchondromata have been observed. 

Sarcoma has its seats of predilection near the ends of the bones. It 
may be spindle-cell or giant-cell or mixed. 

The diagnosis in the early stage cannot be made from syphilis or 
tuberculosis. It will be suggested by absence of syphilitic history or of 



Fig. 205 



THE FOREARM 

Fig. 20G 



385 



Fig. 207 





Figs. 205 and 206. — "Subperiosteal" fracture of both bones near junction of lower and middle 
third of shafts, transverse and same level, in a boy, aged four years. Result of a fall down stairs. 
Anteroposterior view. Fig. 205, shows lateral angular deformity, and Fig. 206, lateral view, indi- 
cates a decided bend toward the palmar aspect. Examination before reduction. Clinical diagnosis 
not difficult, especially in view of deformity. 

Fig. 207. — Fracture of both bones, in adult male, radius transverse, lower and middle thirds; 
xilna longitudinal, through middle third of shaft. (Compound.) In addition a fracture of base 
and of tip of styloid process of ulna. Satisfactory reduction impossible without operation. Antero- 
posterior view. 



tuberculous heredity or lesions elsewhere. In the absence of a syphilitic 
history, a fixed, persistent bone pain, associated with tumor which does 
not involve the nearest joint, is sufficient cause for exploratory opera- 
tion. Even before the development of a palpable tumor the a;-rays 
may show the seat of lesion if not its nature, 
25 



386 THE UPPER EXTREMITY 

Fig. 208 Fig. 209 





Figs. 208 and 209.— Fracture of both bones in lower and middle fourths of shafts, same level, in 
a male, aged thirty-five years. Anteroposterior view, Fig. 208, shows complete lateral displacement 
of both lower fragments to radial side, with over-riding. Lateral view. Fig. 209, shows displace- 
ment of upper ends of lower fragments to palmar aspect. Clinical diagnosis not difficult, but 
a;-rays of great assistance in reduction. 



THE ELBOW. 



The two epicondyles can easily be palpated, even when there is great 
swelling; the inner in its direction indicates the facing of the articular 
surface of the upper extremity of the humerus. Because of an obliquity 
of the joint, there is an outward bend (carrying angle) at the elbow, 
perceptible only when the arm is extended, and more marked in women 
than in men. 

The olecranon forms the bony projection at the back of the elbow. 
To either side of it the joint capsule approaches the surface and here 
and above the head of the radius joint tenderness and effusion are 
earliest detected by palpation. A finger's breadth below the external 
epicondyle the head of the radius may be felt. 



THE ELBOW 



387 



Fig. 210 



Fig. 211 





Fig. 210. — Fracture of both bones near lower end of shafts, "subperiosteal," transverse, same 
level, in a boy, aged fifteen years. Caused by direct violence — struck by automobile crank. 
Clinical diagnosis not difl&cult. Anteroposterior view. 

Fig. 211. — Secondary fracture of both bones in same case as Fig. 210, occurring fifteen weeks 
later, as a result of indirect violence. The lines of fractvu-e are immediately above those of the first 
injury. (Plate reversed in drawing.) 



With the forearm extended, the tip of the olecranon and the epicon- 
dyles are supposed to He very nearly in a plane with which the long 
axis of the humerus makes a right angle. 

Fig. 2121 




Old fracture of shaft of ulna, upper and middle thirds, in an adult female, tmunited. 
Lateral view at elbow; anteroposterior of forearm. 

1 Figs. 212 to 219. Fractures of the shaft of the ulna. Outline drawings from radiographs by 
Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; patients referred from 
service of Dr. Martin, from dispensaries, and private cases of Dr. Pancoast. 



J 



388 



THE UPPER EXTREMITY 



Fig. 213 




"Subperiosteal" fracture of upper and middle thirds of shaft of ulna, in an adult male, resulting 
from direct violence — a blow on back of extended elbow during a game of football. Not diag- 
nosticated clinically; cardinal signs of fracture absent, and attention drawn mainly to the more 
severe subjective manifestations of sprain of elbow. Lateral view at elbow. 



Fig. 214 



Fig. 215 




D 



iniio 



\\\rilf/// 



Figs. 214 and 215. — "Green-stick" fracture of middle of shaft of ulna, in a child, aged three 
and one-half years. Not diagnosticated clinically, but examined because of local tenderness. Fig. 
214, anteroposterior, and Fig. 215, lateral view. 



THE ELBOW 



389 



Fig. 216 



I'lG 217 





Figs. 216 and 217. — Compovind comminuted fracture of middle third of shaft of ulna, in a male, 
aged twenty-nine years. Fig. 216, anteroposterior view, shows only a part of the fracture, while the 
lateral view. Fig. 217, shows a much more extensive break. Clinical diagnosis of injury not difficult, 
but i-rays essential to determine proper reduction. 



Flexion and extension are the only normal movements expressed 
at the humero-ulnar joint. The humeroradio-ulnar articulation per- 
mits rotation of the forearm. 

Normal flexion can be carried to the degree which permits the 
fingers to palpate the acromial process on the same side. Normal 
extension brings the anterior surface of the arm and forearm in the 
same plane with a slight outward angle (carrying angle) at the elbow. 
Rotation of the forearm can be carried through a half circle, the palm 
being made to face directly upward or downward without movement 
at the shoulder. 

After trauma, great swelling, pronounced disability, and intra-articular 
effusion are presumptive evidence of fracture or luxation. 

Inflammation of the joint causes limitation of motion in all directions 
and muscular spasm and atrophy. 

Deformities of the Elbow. — Congenital luxations have been noted 
either of both bones or of the radius alone. Cubitus valgus and varus 



390 



THE UPPER EXTREMITY 



Fig. 218 



Fig. 219 





Fig. 218. — Fracture at junction of lower and middle fourths of shaft of ulna — in an adult male. 
Anteroposterior view, showing complete lateral displacement. (Lateral view indicates none.) 
Clinical diagnosis of fracture and deformity easy. 

Fig. 219. — Oblique fracture at lower end of shaft, or neck, of ulna, in a male, aged fifty-nine years. 
Anteroposterior view. 

are descriptive of lateral deviations of the forearm upon the arm, valgus 
involving abduction (radial side) and varus adduction (ulnar side). 

A similar acquired deformity may be due to a condyloid fracture with 
upward displacement; or it may be an expression of rickets. A slight 
degree of valgus is normal. 

Contractures of the elbow-joint may be cicatricial or myogenic, 
usually of the flexors. Aside from those incident to central or peripheral 
nerve lesions, the commonest cause of muscular contracture is syphilitic 
myositis of the biceps. 

Distortions of the elbow-joint are due to chronic osteoarthritis, which 
may be secondary to trauma, infection, autotoxemia, or arteriosclerosis, 
or may be of neuropathic origin (tabes, syringomyelia). 

Ankylosis of the elbow-joint is secondary to traumatism or arthritis 
in any of its varieties. Pyogenic and gonococcal arthritis are the forms 
most likely to be followed by complete ankylosis. 

Limitation of motion may be partial or complete, may involve the 
motions of flexion and extension, or may be limited to the upper radio- 
ulnar articulation, interfering with pronation and supination. 

Traumatism of the Elbow.— Wounds. — Wounds in the region of 
the elbow may involve the soft parts alone or may enter the joint. In the 
first case examination must be made to exclude the anesthesia and loss 



THE ELBOW 



391 



of motion which characterize lesions of the median, musculospiral, and 
ulnar nerves. 

Wounds involving the joint may be obvious, or, in case of puncture, 
may be difficult of immediate detection. If such wounds are infected 
there is a prompt synovial effusion characterized by a fluctuating swelling 
most marked posteriorly to either side of the olecranon and triceps tendon 
and in the interval between the external condyle and the head of the 
radius; accompanied by great tenderness, severe pain aggravated by all 
motions of the joint, and fixation in a position of slight flexion. The 
constitutional symptoms of septic absorption develop promptly and the 
overlying skin becomes edematous, hot, and red. 

A moderate aseptic effusion may accompany a wound of the joint 
capsule, but not reaching the joint itself. The distinction between this 



Fig. 2201 



Fig. 221 




Fig. 220. — Fracture at junction of upper and middle thirds, and above insertion of pronator 
radii teres, in a male, aged twenty-three years. Anteroposterior ^de■w, showing typical lateral dis- 
placement, persisting after attempted reduction. Clinical diagnosis not difficult, but x-rays essential 
for proper reduction. (Fluoroscope often a valuable aid in reduction of this particular fracture.) 
No anteroposterior deformity shown in lateral view. 

Fig. 221. — Fracture at junction of middle and lower thirds of shaft, in a male, aged twenty-five 
years. Anteroposterior view shows slight comminution and perfect reduction. Clinical diagnosis 
not difficult. There is in addition a fracture of the tip of the styloid process of the ulna, which 
frequently accompanies forearm fractures, but is usually not recognized. 



^ Figa. 220 to 223. Fractures of the shaft of the radius. Outline drawings from radiographs 
by Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; patients referred 
from service of Dr. Martin and from dispensaries. 



392 



THE UPPER EXTREMITY 



Fig, 222 



Fia. 223 





Figs. 222 and 223. — Fracture about middle and lower fourths of shaft, in a male, aged twenty- 
six years. Result of direct violence — struck on palmar aspect by automobile crank. Antero- 
posterior view, Fig. 222, shows lateral displacement to ulnar side. Lateral view, Fig. 223, shows 
complete palmar displacement of lower fragment with over-riding. Clinical diagnosis of fracture 
not difficult. 







Fig. 224 






l" 








' >A 


i #1. 


# ''•■'■ 


« 


^ 


3s 


,* 






m 


pppp. 




jttpM 


i 


-^ 


r 



Syphilitic rupia. Tertiary (years) lesions. Duration, months. No subjective symptoms. 

Patient feeling well. 



THE ELBOW 



393 



effusion and acute pyogenic infection of the joint may be made early 
by aspiration and microscopic and cultural investigation of the contents 
of the joint. 



Fig. 225 




Tuberculous abscess in lower end of radius. Localized pain, tenderness, and swelling, but no 
redness. Secondary inflammatory effusion in wrist-joint. Tuberculous lesion in upper epiphysis 
of femvur and in knee-joint. (Carnett.) 

Sprain of the Elbow. — This is the commonest form of injury about the 
joint, involving chiefly the internal lateral ligament, characterized by a 
history of wrench or twist such as is incident to hurling a ball, followed 
immediately or shortly by disability, pain, tenderness, and swelling, most 
marked over the seat of subcutaneous injury. In one or two days 
following the trauma the skin may exhibit discoloration. 

There may be bleeding into the joint, causing a traumatic synovitis 
with immediate effusion, characterized by swelling and fluctuation on 
either side of the triceps and beneath the external condyle, and fixation 
of the joint in slight flexion. The presence of a joint effusion is so sug- 
gestive of fracture that, when this is present, the a;-rays should always 
be used. 

Persistent pain, tenderness, and disability following sprain, unless this 
be frequently repeated, or no opportunity for recovery has been given, 
are signs which should suggest an associated bone lesion. 

Fractures about the Elbow. — Fracture in the region of the elbow 
commonly involves the lower end of the humerus, at times the olecranon, 
exceptionally the head or neck of the radius, and, almost as a surgical 
curiosity, except as a complication of backward luxation, the coronoid 
process of the ulna. 



394 



Fig. 2261 



THE UPPER EXTREMITY 

Fig. 227 





Figs. 226 and 227. — Incomplete supracondyloid fracture, in a child, aged four years. Antero- 
posterior view. Fig. 226, shows a fissure extending completely across, a short distance above the 
epiphyseal line. The epiphysis for the external condyle is the only one in which ossification has 
begun, and the possibility of detecting an epiphyseal separation of this condyle by the radiograph 
would depend upon an evident alteration in the position and relations of this centre as compared 
with that of the opposite elbow. If reduced, the injury could not be diagnosticated by the 
x-rays unless there was an accompanying break in the bone adjacent. An epiphyseal separation 
of the internal condyle could not be determined radiographically at this age. The lateral view, 
Fig. 227, shows the same fissure extending but about half-way through from before backward. The 
identity of the small process at the lower posterior aspect of the diaphysis is uncertain. 



Fig. 228 



Fig. 229 



Fig. 230 






Figs. 228 and 229. — Incomplete supracondyloid fracture, in a child, aged six years. Antero- 
posterior view, Fig. 228, shows a fissure extending part way across, but it is barely perceptible in 
the lateral view, Fig. 229. Note the increase in size of the centre of ossification in the epiphysis 
for the external condyle and beginning ossification in that for the internal. (See Figs. 226 and 227.) 

Fig. 230. — Complete supracondyloid fracture, in a child, aged eight years. The typical deformity 
of this fracture is shown in the lateral view here represented, and which is the one necessary. The 
fore-and-aft view may not show even the fracture in some instances. The posterior displacement 
is of a moderate degree. Clinical diagnosis of fracture not difficult, but in presence of great amount 
of swelling might be mistaken for dislocation. Radiograph especially valuable for determining 
displacement. 



1 Figs. 226 to 234. Supracondyloid fractures of the humerus. Outline drawings from radio- 
graphs by Dr. H. K. Pancoast in collection of University Hospital a;-ray Laboratory; patients 
referred from services of Drs. Martin, Carnett, and Wood, from dispensaries, and private cases of 
Dr. Pancoast. 



THE ELBOW 



395 



Fig. 231 



Fig. 232 





Figs. 231 and 232. — Supracondyloid fracture, in a child, aged nine years. Lateral view. Fig. 
231 shows the typical posterior deformity, but the anteroposterior view. Fig. 232, indicates in addi- 
tion a very unusual lateral displacement to the radial side. The smooth appearance of the upper 
edge of the lower fragment gives somewhat the impression of an epiphyseal separation, but is due 
to the articular surface showing above in place of broken surface because of the peculiar angle 
at which the part was exposed on account of the dressing on an internal rectangular splint. This 
is a proof of the necessity of examining in both directions, even under such difficulties as men- 
tioned. Note beginning ossification of epiphysis for olecranon in Fig. 231. 



Fig. 233 



Fig. 234 





Fig. 233. — Supracondyloid fracture in a child, aged eight years. Lateral view before reduction 
shows an extreme degree of posterior displacement of lower fragment, as compared with Fig. 230. 

Fig. 234. — Supracondyloid fracture, in a male, aged sixty years, old and ununited. Clinical 
diagnosis of injury somewhat difficult at this time, but x-rays show its exact nature, amovmt of 
callus and the deformity. This fracture is not nearly so common in adults as in children. 

Fractures of the lower end of the humerus may be supracondyloid, 
intercondyloid, condyloid, epicondyloid, or epiphyseal. All these frac- 
tures, except the sypracondyloid and epicondyloid, involve the elbow- 
joint, and are accompanied by almost immediate and pronounced 
swelling due at first to blood effusion into and around the joint, later to 



396 



THE UPPER EXTREMITY 



traumatic inflammatory reaction. The rapid and extensive swelling 
is in itself presumptive evidence of the presence of fracture as opposed 
to sprain. 

Supracondyloid fracture, common in children under ten years of age, 
follows a fall on the bent elbow or the outstretched hand. It is usually 
oblique from below upward and from in front backward. Hence the 
lower end of the upper fragment projects anteriorly and occasionally 
injures the bloodvessels or nerves. When the injury is due to a fall 
upon the bent elbow (adults) the line of fracture may be oblique from 
in front downward and backward. Hence, the lower end of the upper 
fragment projects backward, the lower fragment lying forward and 
usually inward. 

Rapid extra-articular swelling, the preservation of the normal relation 
of the tip of the olecranon, the head of the radius, and the internal and 



Fig. 2351 



Fig. 236 





Fig. 235. — Fracture of both condyles, in male, aged fifty-four years, resulting from a fall out of 
a window. Wide separation of fragments. Clinical diagnosis not difficult, except as obscured by 
great swelling. Exact nature of injury more readily determined by radiograph, which also shows 
exact deformity. Anteroposterior view represented, and is the more important one, although 
difficult to obtain on account of flexion of forearm. (Latter accounts for distortion of bones of 
forearm.) 

Fig. 236. — Fracture of both condyles, in a girl, aged thirteen years, with lateral separation and 
upward displacement of fragments. The smooth upper surfaces of the fragments suggests a separa- 
tion of the lower epiphysis (the two condylar epiphyseal centres being fused at this age), but the 
portion of the shaft attached to the internal condylar fragment indicates that the epiphysis has 
united on the inner side at least. The patient's age being that at which this epiphysis begins 
to unite, the injury is probably both a fracture and an epiphyseal separation above the condyles, 
and a fracture between them. The centre for the internal epicondyle has not yet vmited. Clinical 
diagnosis of injury not difficult, but radiographs essential to determine displacement. Proper 
reduction was impossible without operation. 

1 Figs. 235 and 236. Fractures at the lower end of the hvunerus — both condyles. Outline 
drawings from radiographs by Dr. H. K. Pancoast in collection of the University Hospital x-ray 
Laboratory; patients referred from services of Drs. White and Martin. 



THE ELBOW 



397 



external condyle, estimated by comparison with the uninjured side, 
crepitus and preternatural mobility above the condyles elicited by 
grasping the elbow and rocking it from side to side, limited flexion and 
exaggerated extension, deformity obvious on both palpation and inspec- 
tion, and shortening as measured from the acromion to the external 
epicondyle, make the diagnosis easy. 

Condyloid fracture may be of either the internal or the external condyle. 

Fractures of the external condyle, especially frequent in children, 
involve the capitellum, sometimes the trochlea. They are characterized 
by swelling, pain, and tenderness, which reach their maximum intensity 



Fig. 2371 



Fig. 238 




Fig. 237. — Fracture of the external condyle 
in a child, aged four years, the line of fracture 
appearing as a fissure immediately above the 
epiphyseal line, and extending into it. Shows in 
anteroposterior view only. Clinical diagnosis 
difficult — depending mainly upon pain on motion 
and local tenderness. (No displacement, and 
crepitus and preternatural mobility absent.) 

Fig. 238. — Normal elbow of the same case as 
Fig. 237, and same view (anteroposterior). 



Fig. 240 




Figs. 239 and 240. — Fracture external condyle, 
in a boy, aged five years, at a higher level than the 
preceding, and with slight downward and outward 
displacement, latter shown in anteroposterior 
view. Fig. 239. (Lateral view, Fig. 240.) Clin- 
ical diagnosis not so difficult as in preceding case, 
deformity and crepitus being determinable. 



1 Figs. 237 to 247. Fractures of the lower end of the humerus — external condyle. Outline 
drawings from radiographs by Dr. H. K. Pancoast in collection of University Hospital a;-ray 
Laboratory; patients referred from service of Dr, Frazier, from dispensaries, and private cases of 
Dr. Pancoast, 



398 THE UPPER EXTREMITY 

Fig. 241 Fig. 242 





Figs. 241 and 242. — Fracture of the external condyle in a boy, aged ten years, the line of fracture 
appearing as a fissure just above the epiphyseal line, and tending almost to an incomplete fracture 
of the internal condyle as well (or there may have been a separation of the unossified epiphysis) 
without displacement. Both this case and Fig. 237 might be regarded as epiphyseal separations. 
In the absence of displacement the clinical diagnosis is difficult, crepitus being absent or ill-defined. 
Fig. 241, anteroposterior, and Fig. 242, lateral view. 



1 



Fig. 243 



Fig. 244 





Figs. 243 and 244. — Peculiar fracture of external condyle — separation of anterior portion of 
articular surface of capitellum, in a female, aged forty-five years. Upward and forward displace- 
ment of fragment. Clinical diagnosis difficult, deformity not in evidence, preternatural mobility 
impossible to determine, and crepitus hard to locate. Exact diagnosis essential to prevent future 
disability, and readily shown by radiographs. Fig. 243, anteroposterior view, and Fig. 244, lateral 
view. 



THE ELBOW 



399 



Fig. 245 



Fig. 246 





Figs. 245 and 246. — Old fracture of external condyle, in a male, aged twenty-one years, with 
more or less union of fragment in peculiar position, the broken surface having rotated outward, 
and the articular surface inward nearly 90 degrees on anteroposterior axis. Very poor surgical 
result from x-ray standpoint, but fairly good functionally. Radiographs made because of a recent 
injury. (Negative.) Fracture and displacement both shown in anteroposterior view, Fig. 245, 
but neither in lateral view. Fig. 246. 

Fig. 247 




Fracture of external condyle and tip of coronoid process of ulna, with lateral outward displace- 
ment of condylar fragment and corresponding dislocation of both bones of forearm. Male, 
aged twenty-seven years. Clinical diagnosis not difficult unless obscured by great amount of 
swelling. Anteroposterior radiograph shows exact nature of injury and the displacement more 
readily, however. 



400 



THE UPPER EXTREMITY 



over the external condyle; outward displacement of the head of the 
radius which moves with the condyle, and usually crepitus and mobility 
detected by direct palpation and manipulation of the condyle while 
traction is exerted upon the forearm and it is rocked laterally. 

Fracture of the internal condyle involves a part or the whole of the 
trochlea, often a part of the capitellum. It is evidenced by swelling, 
pain, and tenderness, particularly marked in the region of the internal 
condyle, and crepitus elicited by direct palpation. Traction, flexion, 
extension, and lateral rocking may demonstrate crepitus and preter- 
natural mobility if it cannot be felt by grasping the condyle and attempt- 
ing to move it in various directions. There is usually a partial back- 
ward and inward displacement of the ulna which carries the internal 
condyle with it and which is easily reduced but as easily recurs. 

Fracture of the internal epicondyle, usually, but not always, extra- 
articular, is marked by sharply localized pain, tenderness, and swelling, 
and the detection of preternatural mobility and crepitus by direct palpa- 
tion. It is sometimes complicated by injury of the ulnar nerve. 



Fig. 2481 



Fig. 249 





Figs. 248 and 249. — Old (thirteen months) ununited fracture of the internal condyle, in a male, 
aged twenty-one years. The lateral view, Fig. 248, shows the fragment completely separated and 
displaced anteriorly, while the anteroposterior picture. Fig. 249, is remarkable in giving the impres- 
sion of a perfectly normal elbow, with not the slightest suggestion of a fracture, even though 
details are clear. 



1 Figs. 248 to 252. Fractures of the lower end of the hvunerus — internal condyle and epicondyles. 
Outline drawings from radiographs by Dr. H. K. Pancoast in collection of University Hospital 
a;-ray Laboratory; patients referred from dispensaries. 



THE ELBOW 



401 



Fig. 250 



Fig. 251 





Figs. 250 and 251.— Fracture of the internal epicondyle, in a male, aged eighteen years (being 
about age of union, may be epiphyseal separation), resulting from either direct violence or mus- 
cular action during a wrestling match. Complete separation (muscular attachments). Fig. 250, 
anteroposterior, and Fig. 251, lateral view. 



Fig. 252 




Fracture of both epicondyles, in a male, aged twenty-four years. Very slight displacement. 
Clinical diagnosis not difficult. Anteroposterior view. (Lateral view practically negative.) 
26 



102 



THE UPPER EXTREMITY 



Supracondyloid and inter condyloid fractures are characterized by a line 
or lines of break passing into the joint in addition to the supracondyloid 
fracture. They are usually due to falls upon thq elbow, and are inci- 
dent to the direct splitting force transmitted from the olecranon. Such 
fracture may appear in the form of a T or a Y, or may be greatly com- 
minuted. They occur in the adult as well as in children. 

The apparent reduction of the deformity is simple, but it is as readily 
reproduced. 

Intercondyloid fracture is attended by rapid and pronounced swell- 
ing within and around the joint, which is held in a position of slight 
flexion. On grasping and attempting to move the condyles with the 
finger and thumb of each hand, preternatural mobility and crepitus 
can be elicited, the condyles moving independently of each other. If 
the ulna is driven between the condyles, the olecranon will be displaced 
upward and backward. The distinction from luxation is based upon 
preternatural mobility as opposed to fixation, the ease of apparent 
reduction, and the prompt reappearance of deformity when the reduc- 
ing force is removed. Also by bone crepitus, obvious displacement 
of the condyles, and a marked increase of the intercondyloid measure- 
ment. Extensive comminution with great displacement of fragments 
is common, nor can this be accurately diagnosticated except by the 
.r-ray. 

Fig. 2531 Fig. 254 





Fig. 253. — Fracture of extreme tip of olecranon, in an adult male, result of direct violence (struck 
by automobile crank). Triceps insertion not involved, therefore no displacement. Small frag- 
ment covered by bursa, and diagnosis difficult on account of swelling. 

Fig. 254. — Peculiar fracture of olecranon comparable to a rupture of the triceps tendon. Sepa- 
ration from posterior surface of scale-like fragment representing attachment of the tendon. Wide 
separation from retraction of latter. Adult male. 

1 P'igs. 253 to 262. Fractures of the olecranon and coronoid processes. Outline drawings from 
radiographs by Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; patients 
referred by or from services of Drs. Martin, Frazier, and Siter, and from dispensaries, and private 
cases of Dr. Pancoast. 



THE ELBOW 



403 



Fig. 255 



Fig. 256 





Fig. 255. — Typical fracture of olecranon, with usual 
degree of separation from action of triceps, in a male, aged 
twenty-seven years. Clinical diagnosis not difficult. 
X-rays show no complicating fracture. 

Fig. 256. — Old "subligamentous" fracture of olecra- 
non, in aduH female, diagnosticated and treated as rup- 
ture of triceps tendon. First radiograph, two years 
after injury, indicates fibrous but no bony union. Caused 
by direct violence — fall from trolley car. 



Fig. 257 



Fig. 258 




Figs. 257 and 258. — Fracture of olecranon and 
incomplete fracture of external condyle of hum- 
erus, in male, aged forty-nine years, due to direct 
violence — fall on elbow. Lateral view, Fig. 257, 
shows only fracture of olecranon, without sepa- 
ration, and slightly below usual level. Antero- 
posterior view. Fig. 258, shows only the fracture 
of the external condyle. Both views necessary 
for complete diagnosis. Clinical diagnosis of 
condylar fracture difficult. (Absence of de- 
formity, mobility, and crepitus.) Also, more 
conspicuous olecranon fracture apt to detract 
attention from latter. 




404 



THE UPPER EXTREMITY 
Fig. 259 




Incomplete longitudinal fissured fracture of olecranon and upper portion of shaft of ulna, 
in a male, aged twenty-five years, result of gunshot injury. 

Fig. 260 




Normal elbow of a boy, aged sixteen years, showing the epiphyseal line just before union of 
epiphysis of olecranon with shaft, occurring at this age. This line is often mistaken for fracture, 
and a year or two later such an appearance would imply the latter. 



Fig. 261 



Fig. 262 




Fig. 261. — Fracture of tip of coronoid process of ulna, in a male, 
aged thirty-six years, resulting from a fall on the elbow. (Un- 
usual.) Clinical diagnosis difficult, pain on movement, limitation of 
motion, and local tenderness, but absence of cardinal signs. 

Fig. 262. — Example of a ' 'sprain fracture" at elbow, separation of 
inner edge of coronoid process representing the attachment of a 
portion of the internal lateral ligament. Equivalent to a severe 
sprain. Pain and local tenderness led to the suspicion of a fracture 
of the internal condyle. (Male, aged twenty-nine years.) 




THE ELBOW 



405 



Fractures of the olecranon, due to falls on the elbow or muscular 
action, may be extra-articular in the form of a tearing off of the bone 
attachment of the triceps tendon; usually they are intra-articular and 
are attended by an abundant joint effusion. They are manifested by 
pain and tenderness, most marked at the seat of injury, inability to 
extend the arm, or to extend it forcibly, pain experienced in attempting 
this motion, separation of fragments and preternatural mobility detected 
by direct palpation. When the bones are held in place by the invest- 
ing fibrous tissue, persistent localized tenderness, swelling, pain and 
loss of power on attempting extension may be the only symptoms. 
The rr-rays may be needful for diagnosis; also, in young people, an 
interpreter familiar with epiphyseal development. 

Fracture of the coronoid process of the ulna, a common complication 
of backward dislocation, rare as an isolated lesion, is attended by imme- 
diate joint effusion and persistent tenderness and pain located in the 
bend of the elbow to the inner side of the biceps tendon. The diagnosis 
must be made by the a:-rays. 

Fractures of the head and neck of the radium due to a fall upon the 
hand, probably with the arm straight, are characterized by an effusion 
into the entire joint, tenderness most marked over the head or neck of 
the radius, and, if the fracture be complete and involve the neck, failure 
of the head to follow the shaft in the motions of pronation and supina- 



FiG. 2631 



Fig. 264 




Figs. 263 and 264. — Incomplete longitudinal fissured fracture of head of radius in a female, aged 
twenty-five years, resulting from indirect violence. (Fall down stairs, striking on hand.) Antero- 
posterior view (Fig. 263) is most likely to show such a break. Clinical diagnosis difficult, and this 
type of fracture not detected in majority of cases. Only signs, pain on motion, local tenderness, 
and ill-defined "click" on rotation. Orbicular ligament prevents displacement. Lateral view 
(Fig. 264) frequently does not show this type on account of overlying olecranon. 



1 Figs. 263 to 271. Fractures of the head and neck of radius. Outline drawings from radio- 
graphs by Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; patients 
referred by or from service of Dr. Martin, and from dispensaries, and private cases of Dr. Pancoast. 



406 



THE UPPER EXTREMITY 

Fig. 265 




Incomplete longitudinal fracture (fissured) of head of radius, and either a fracture or epiphyseal 
separation of internal epicondyle of humerus, in a boy, aged seventeen years. (Very near age 
of union of this epiphysis.) Diagnosis of latter injury not difficult clinically. Neither fracture 
could be detected in the lateral view. 

Fig. 266 




Old (six months) comminuted and impacted fracture of head and neck of radius, united with 
permanent displacement of fragments. Female, aged thirty-two years, referred for determina- 
tion of cause of partial ankylosis of joint. Clinical diagnosis of such a type of fracture should 
not have been difficult at time of injury. 



THE ELBOW 407 

Fig. 267 Fig. 268 





Figs. 267 and 268. — Old (five weeks) comminuted fracture of head, neck, and upper portion of 
shaft of radius in an adult male. The lateral view, Fig. 267, shows a longitudinal split through the 
head, neck, and shaft, and a large fragment of the head completely separated and displaced outside 
of the orbicular ligament. Reduction of latter by manipulation impossible. Anteroposterior 
view, Fig. 268, important and remarkable for the reason that it presents the appearance of a per- 
fectly normal elbow. Case not properly diagnosticated at time of injury, although an exact clinical 
diagnosis would be very difficult without the radiograph. 



Fig. 269 



Fig. 270 



Fig. 271 





Figs. 269 and 270. — Impacted fracture of neck of radius, in a boy, aged nine years, resulting from 
a fall on the hand. Clinical diagnosis difficult because of absence of crepitus and deformity, and 
the fact that the head rotated with the shaft. Pain on rotation and local tenderness most promi- 
nent signs. Fracture of neck and epiphyseal separation of head are more common in children 
than fracture of the head. 

Fig. 271. — Impacted fracture of neck of radius and fracture of bony portion of olecranon, in a 
child, aged five years. Latter "subligamentous," and clinical diagnosis not difficult, as was the 
case with radial fracture. These two fractures not uncommonly occur together in children. Child 
too young for appearance of ossification in olecranon epiphysis, and likewise in that of head of radius. 
Lateral view. 



408 



THE UPPER EXTREMITY 



tion. Shortly after the injury these motions will be so painful that 
they cannot be performed actively nor tolerated passively. Crepitus 
may be elicited. The diagnosis in fissured or impacted fractures, and 
in most of the complete ones must be made by the a;-rays, or, in the 
absence of this, may be based upon persistent disability and localized 
tenderness. 

The diagnosis of all injuries about the elbow-joint should be revised 
by careful ar-ray pictures interpreted, in the case of children, by one 
familiar with epiphyseal development and ossifying centres. The 
prognosis in all these injuries must be guarded in so far as complete 
functional and cosmetic restoration are concerned. 

Dislocations of the Elbow. — Dislocations of the elbow, usually of both 
bones backward, common in young people, are usually due to falls, 
the weight of the body being suddenly arrested by the outstretched 

Fig. 2721 




Unusual form of injury in a man, aged fifty-seven years, result of a fall either on hand or 
elbow, probably the former. Definite clinical diagnosis could not be made. Evidently the force 
exerted through radius caused more or less impacted fracture of external condyle. Force on ulnar 
side probably largely expended in a transverse fractiire of ulna below base of coronoid. In addition, 
an incomplete fracture of internal condyle. (Both condyles complete would constitute "V" type.) 



1 Figs. 272 to 284. Dislocations, unusual fractures, and complex injuries at the elbow. Outline 
drawings from radiographs by Dr. H. K. Pancoast in collection of University Hospital x-ray 
Laboratory; patients referred by or from service of Dr. Martin and from dispensaries, and private 
cases of Dr. Pancoast. 



THE ELBOW 



409 



Fig. 273 



Fig. 274 





Figs. 273 and 274. — Oblique fracture, slightly comminuted, at junction of head and neck of radius, 
and a fracture through the ulna at base of coronoid process. Adult female. Exact cause not 
known. Fig. 273, lateral view, shows the fragment of the head of the radius completely de- 
tached, but almost entirely obscured by the olecranon. Fig. 274, anteroposterior view, shows 
the head displaced upward and backward behind the external condyle and turned with the articular 
surface facing anteriorly. Exact clinical diagnosis extremely difficult, especially in regard to the 
radial fracture. Radiograph indicates reduction of the head impossible. 



hand with the elbow-joint in full extension. The ligaments are usually 
torn from their attachment to the humerus, the internal lateral often 
carrying its epicondyle with it. Fracture of the coronoid process is 
also noted. 

The diagnosis is based upon the relative position of the external and 
internal condyle of the humerus to the olecranon process and head of 
the radius. In the normal joint with the arm extended, the tip of the 
olecranon lies very slightly above a line drawn transversely across the 
back of the elbow from one condyle to the other. In backward luxa- 
tion the tip of the olecranon lies well above this line. There is an 
elastic resistance to flexion beyond an obtuse angle; when carried as 
far as possible the olecranon projects backward as compared with the 
same bony process of the sound side. Behind the external condyle the 
head of the radius can be felt in its abnormal position. The smooth, 
rounded, articular extremity of the humerus can be felt in front, and 
below the bend of the elbow. Compared measurements of the injured 
and the healthy arm show shortening as measured from the condyle 



410 



THE UPPER EXTREMITY 



to the styloid process; absence of shortening as measured from the 
acromion to the external condyle. 



Fig. 275 



Fig. 276 





Figs. 275 and 276. — Complicated elbow injury in a woman, aged fifty-nine years. Had been 
diagnosticated and treated by her physician as a sprain. The radiographs made several weeks 
later show the following: (a) Unreduced posterior dislocation of both bones; (&) comminuted frac- 
ture of the head of the radius; (c) comminuted fracture of the shaft at about the biceps insertion; 
{d) fracture of she tip of the coronoid process of the ulna (Fig. 275). Clinically, the serious 
nature of the injury should have been evident, and a diagnosis of the dislocation and the lower 
radial fracture should have been made readily, although complete diagnosis would have been prac^ 
tically impossible without an x-ray examination. Fig. 275, lateral view; Fig. 276, anteroposterior 
view. 

Fig. 277 




Fracture of the neck of the radius and of the ulna below the base of the coronoid process, in an 
adult female, resulting from a fall on the arm and elbow. (Lateral view.) Exact diagnosis was 
uncertain clinically, but was readily determined radiographically, and reduction much simplified. 



THE ELBOW 



411 



Fig. 278 



Fig. 279 





Figs. 278 and 279. — Unreduced dislocation elbow, both bones posterior, in an adult female. Clini- 
cal diagnosis not difficult, but injury in this case not recognized by physician. Caused by fall from 
car. In Fig. 279, anteroposterior view, the appearance of lateral displacement to radial side is one 
always observed in the radiograph in this direction. 



Fig. 280 



Fig. 281 





Figs. 280 and 281. — Unreduced dislocation of elbow, lateral, both bones to ulnar side, in male, aged 
twenty-three years. Clinical diagnosis of the dislocation not difficult, but radiograph essential 
in excluding a possible complicating fracture, for which both views are necessary, although the 
luxation is shown in the fore-and-aft one only. 



412 



THE UPPER EXTREMITY 



In supracondyloid fracture the angular projection of the lower end 
of the upper fragment is felt in front but is above the bend of the 
elbow; there is no resistance aside from that incident to pain to either 
flexion or extension; there is usually preternatural lateral mobility. 

Forward luxation of both hones of the forearm is extremely rare. It 
is due to direct force applied to the back of the flexed elbow, and is not 
infrequently complicated by fracture of the olecranon, in which case 
the fragment attached to the triceps tendon remains in place. This 
dislocation would seem impossible without such a fracture or a rupture 
of the tendon of the triceps. 



Fig. 282 



Fig. 283 



Fig. 284 





Fig. 282. — Unreduced anterior dislocation of head of radius, in a child, aged seven years. 
(Recent.) Ossification has not begun in the epiphysis for the head. 

Figs. 283 and 284. — Old, unreduced, posterior dislocation of head of radius, in a female, aged 
twenty-one years. Not diagnosticated or treated, although the condition was easily recognized at 
the time the radiographs were made. Fig. 283, nearly lateral view, shows ulna in place, but head 
of radius displaced back of olecranon. Fore-and-aft view, Fig. 284, shows it above and behind 
the articular surface of the external condyle. 

Lateral luxations of both bones of the forearm, incomplete to the inner 
side or complete or incomplete to the outer side, are characterized by 
an obvious deformity, the condyle bulging on one side and the displaced 
ulna or radius on the other. Flexion to or beyond a right angle is pos- 
sible in these cases and external displacement is complicated by fracture 
of the inner epicondyle. 

Divergeiit dislocation of the radius and uhia may be anteroposterior, 
in which case the ulna is displaced behind the articular surface of the 
humerus and the radius in front of it; or transverse, the ulna being 
displaced inward and the head of the radius outward. 

Dislocation of the ulna alone (rare) is characterized by extension 
of the arm with limitation of flexion but free rotation. Palpation 
shows the head of the radius in place, the olecranon displaced posteriorly, 
the trochlear surface of the humerus forming a projection in front. 



THE ELBOW 



413 



Dislocation of the radius is likely to be forward, and may be compli- 
cated by fracture of the ulnar shaft. It may occur from a fall on the 
hand. Flexion is limited to a right angle; on extending the arm, 
the head of the radius is found lying in front of its normal position 
in the bend at the elbow; there is a depression in its normal position 
below the condyle. Outward luxation of the radius (rare) is readily 
recognized by the displaced bone. It has been frequently complicated 
by fracture involving the inner articular surface. 

Fig. 285 




Backward luxation of ulna and radius. Treated originally for sprain. Exhibiting limited 
flexion and extension. Shortening of forearm (from external condyle to styloid process of radius) , 
backward projection of the olecranon, prominence of the biceps tendon. Accentuation of the de- 
pression behind the external condyle. Backward and outward displacement of the head of the 
radius. 



Subluxation of the radium is supposed to be due to a partial displace- 
ment of the head of the bone from the orbicular ligament. It is observed 
only in young children who have been lifted or pulled by the hand or wrist. 
There is often, but not always, sudden pain. The affection is marked by 
disability, the arm hanging at the side with slight flexion at the elbow 
and pronation of the forearm. The only point of tenderness is over 
the head of the radius. Supination is limited. The diagnosis is made 



414 THE UPPER EXTREMITY 

by the readiness with which the condition is cured by traction and 
forcible supination. 

Inflammation of the Elbow. — ^The skin overlying the region of 
the elbow, is subject to the inflammatory affections observed in other 
parts of the body. On the back of the elbow the lesions of psoriasis 
and those of secondary and tertiary syphilis are likely to be well marked. 
In the latter case the eruption is characterized by its indolence, often 
its symmetry, by its circinate borders, its history, and its prompt yielding 
to specific treatment. 

Acute Circumscribed Inflammation. — Acute circumscribed inflamma- 
tion, involving the soft tissues about the elbow-joint, may appear as a 
boil or carbuncle, as a bursitis or an adenitis. 

Acute Bursitis. — ^The bursa commonly involved is that lying between 
the olecranon and the skin. The affection is usually traumatic, often 
accompanied by a wound. It is marked by heat, redness, swelling, 
fluctuation, and often fine crepitation from blood effusion. If pus forms, 
the local inflammatory symptoms are rapidly progressive and are asso- 
ciated with general symptoms of septic absorption. The diagnosis is 
based on the seat of the inflammation which is distinctly subdermal, 
fluctuation from the first, and absence of joint involvement. 

Chronic bursitis, which may be traumatic or a local expression of 
toxemia or infection, is characterized by the rapid or slow formation 
of a usually fluctuating tumor in the position of the olecranon bursa. 

Acute adenitis, secondary to infection of the ulnar side of the hand or 
forearm, develops in front of the internal condyle or just above it, 
forming a tender, primarily hard tumor, over which the skin is freely 
movable. This may subside or suppuration may occur, in which case 
the skin becomes reddened, edematous, and adherent, and softening 
takes place in a few days. There is often associated axillary enlarge- 
ment, and constitutional symptoms of septic absorption are usually 
present. 

Inflammation of the Elbow-joint. — ^The elbow follows the knee 
in the frequency with which it is subject to inflammation. When 
distended by exudate, the elbow-joint is fixed in a position of slight 
flexion (130 degrees). The swelling due to the joint effusion is most 
easily perceived at either side of the olecranon process and triceps 
tendon, and between the external condyle and the head of the radius. 

Acute Arthritis of the Elbow. — ^This is usually traumatic, rheumatic, 
or gonorrheal. 

In its acute suppurative form it is due to direct infection by wound 
or extension from surrounding parts, as from osteomyelitis, epiphysitis, 
or periarticular suppuration; or is a local expression of a general 
infection (pyemia, typhoid, pneumonia). 

Acute traumatic arthritis, if incident to contusion or sprain, causing a 
blood effusion into the joint, is characterized by pain, disability, dis- 
tention of the joint capsule, and moderate periarticular swelling, with 
prompt (days) and complete subsidence. Persistent pain, tenderness, 
disability, and swelling suggest a bone lesion or a beginning tuberculosis. 



THE ELBOW 415 

A form of recurring traumatic arthritis is that incident to a loose 
body in the joint, which may be present without symptoms or may 
cause sudden painful locking, limiting extension, and followed by effu- 
sion into the joint. The diagnosis is made by the suddenness of the 
attacks of painful locking, their recurrence, inexplicable except on 
the basis of a movable mechanical obstruction and, at times, by the 
detection of the foreign body on palpation. 

Acute rheumatic arthritis of the serous type is suggested by high fever, 
acid sweats, involvement of other joints, and the absence of demon- 
strable systemic or local infectious cause. 

Acute gonococcal arthritis is usually of the serofibrinous and peri- 
articular form, is exceedingly painful, obstinately persistent, and results 
in joint destruction and ankylosis. The diagnosis is suggested by the 
demonstration of a gonococcal focus elsewhere, and is made at times by 
bacteriological examination of the joint contents. 

Acute suppurative arthritis is characterized by the rapid onset and 
progression of local symptoms and the prompt development of profound 
sepsis. Early diagnosis, when this is not obvious from the preceding 
history, should be made by joint aspiration. 

Chronic Arthritis of the Elbow. — This may be post-traumatic, syphilitic, 
incident to other forms of chronic infection or toxemia or neuropathic. 
It is usually tuberculous. 

Post-traumatic chronic arthritis gives a history of either severe or 
frequently repeated slight traumatism. It is characterized by bony 
deformity with consequent mechanical irhpediment to free mobility, 
together with pronounced periarticular thickening, and pain on use. 

Tuberculous Arthritis. — ^Tuberculous arthritis is characterized, first, 
by pain, limitation of motion and muscular atrophy, which may 
persist for weeks or months preceding appreciable swelling. There 
is often at this period a point of greatest tenderness to pressure. The 
focus of infection is usually in the ulnar or humeral epiphyses, excep- 
tionally that of the radius. In its later development, the pallid, fusi- 
form swelling, destruction of whole or part of the joint, softening, and 
sinus formation are sufficiently characteristic. 

The diagnosis should be suggested by a pain in the elbow without 
adequate cause, persistent and growing worse; by limitation of motion; 
and by muscular atrophy. The seat of infection should be determined 
by the ic-rays. 

Associated tuberculous lesions elsewhere or the tuberculin test may 
aid in the diagnosis. 

Syphilitic Arthritis. — Syphilitic arthritis of the elbow, aside from 
that form characterized by slight intra-articular effusion in the early 
secondary stage, so closely resembles tuberculous infection that the 
diagnosis must be based upon the history, associated symptoms, the 
therapeutic test, and the negative evidence afforded by the tuber- 
culin test. 

Osteochondritis of hereditary lues may cause epiphyseal disjunction 
and flail-joint. . 



416 



THE UPPER EXTREMITY 



Neuropathic Arthritis. — Neuropathic arthritis of the elbow is symp- 
tomatic of syringomyelia or tabes; it is characterized early by hydrops, 
later by gross bony deformity and rough crepitation without subjective 
symptoms, the disability being purely mechanical. The diagnosis is 
based upon the absence of pain, the surprisingly slight disability, and 
associated symptoms of the major malady. 

The benign and malignant tumors about the elbow do not depart 
from type. Those of the bone are characterized early by pain which 
is persistent and localized, later by rapid growth. They should be 
diagnosticated by excision and microscopic examination. 

THE ARM AND SHOULDER. 

The shoulder owes its rotundity to the deltoid muscle supported 
beneath by the acromion process and the greater tuberosity of the 
humerus. The latter, projecting beyond the anterior third^of the 




Trapezius muscle. 



Outer end of clavicle. 
Most frequent site of frac- 
ture of the clavicle. 
Acromion process. 
Infraclavicular triangle. 
Greater tuberosity of humerus. 
Coracoid process. 
Lesser tuberosity. 



Groove between the del- 
toid and pectoral is 
major muscles. , 



Insertion of the deltoid 
muscle. 



Nipple in 4th interspace. 



Prominence of triceps. 

Prominence of biceps. 

Apex beat in 5th Inter- 
space one inch to inner 
side of nipple. 



Surface markings of arm and shoulder. (G, G. Davis ) 



THE ARM AND SHOULDER 417 

acromial margin, underlies the most prominent (point) part of the 
shoulder, and, if widely displaced, as in luxation, allows the deltoid to 
fall inward, making the acromion unduly sharp and prominent. 

The greater tuberosity and, by outward rotation, the lesser tuber- 
osity and the bicipital groove between them can be felt in thin subjects 
when there is no local swelling. 

Since the sheath of the long head of the biceps communicates directly 
with the joint, effusions into the latter, if abundant, may be detected 
by swelling in the bicipital groove. 

The coracoid process can be felt in the groove between the great 
pectoral and the deltoid muscle by deep pressure a finger's breadth 
below the junction of the middle and outer third of the clavicle. 

The clavicle is palpable throughout its course; its outer articulation 
is often congenitally placed on the upper instead of the anterior sur- 
face of the acromial process, thus giving the impression of displace- 
ment. 

Examination of the shoulder should first be visual, the patient being 
stripped to the waist for comparison of the two sides. Then functional, 
th'fe patient attempting to move the two arms together in the directions 
indicated. Palpation and passive motion are next practised. Finally, 
in case of doubt, the rr-rays should be used. 

The normal shoulder-joint should allow the heel of the hand to be 
placed on the acromion process of the opposite side, with the inner 
surface of the arm pressed closely against the chest; the palm to be 
carried around the opposite side until it rests on the midposterior por- 
tion of the neck, with the arm at a right angle to the long axis of the 
body; both hands to be carried backward until the knuckles of each 
touch the scapular angle of the other side; both arms to be carried out- 
ward without moving either scapula until they form a right angle with 
the long axis of the body; both arms carried upward until the midbicipital 
region of each touches the ear of its corresponding side. Normal 
rotation is through about a quarter of a circle. 

The usual effect of trauma is bruise or sprain, the prognosis of which 
must be guarded. Pronounced periarticular swelling, following trauma, 
is presumptive evidence of more serious injury. 

Obvious tumors of the deltoid region are usually not from the joint. 
They are generally fatty, bursal, or sarcomatous. Joint inflammations 
limit motion in all directions, but not equally so. Tuberculous inflam- 
mation involves the humerus and scapula more frequently than it does 
the joint. 

Sprengel calls attention to a congenital deformity usually affecting- 
the scapula of the left side, which is abnormally elevated and rotated. 
Because of the rotation the supraclavicular space is practically obliter- 
ated. Disability is most marked when efforts are made to elevate 
the arm. There is often a fibrous or bony attachment of the scapula 
to the cervical vertebras. 
27 



418 THE UPPER EXTREMITY 

Deformities of congenital origin, such as absence of the entire upper 
extremity, or shoulder, insertion of the hand, the arm and forearm 
being absent, are obvious. 

The same may be said of acquired deformities, such as the curved 
and stunted humerus of rickets, or the atrophied, flail-like, useless 
joint of infantile palsy, probably incident to birth trauma or acute 
poliomyelitis. 

Kirmesson notes that in cases of infantile palsy the upper fibers of 
the trapezius remain sound and hence are able to raise the front of the 
shoulder. An early diagnosis may enable much to be done for the pre- 
vention of ultimate crippling. 

Limitation of motion, or ankylosis of the shoulder, may follov^ 
muscular contracture or any of the forms of arthritis or periarthritis. 
Even when the shoulder-joint is completely ankylosed, there may be 
comparatively free movement. In conducting an examination, the 
scapula should be grasped w^ith one hand, w^hile the arm is moved in 
various directions by the other. In case of complete joint fixation, 
the shoulder blade will be found to participate in all the movements 
of the humerus. When the joint is excessively tender, a correct esti- 
mation of the limitation of motion calls for the administration of an 
anesthetic. 

Traumatism of the Arm and Shoulder. — Wounds and, indeed, all 
severe traumatisms call for an examination of the sensory and motor 
power of the hand and arm, in order to determine the presence or 
absence of nerve lesion, and the search for the radial pulse as an 
assurance against occlusion of the main artery. 

Rupture of the muscles, commonly of the biceps, is characterized by 
sharp pain, sudden loss of power, and the formation of a soft tumor, 
pressure on which shows a break in continuity aggravated by contrac- 
tion. Rupture of the tendon of the biceps is characterized by the same 
symptoms. W^hen the long head of the biceps is ruptured, on account 
of its deep position the break in continuity may not be discovered. 
The disability and sharp pain incident to muscular action, often the 
sensation of something having given way, and the partial luxation 
inward and forward of the head of the humerus are characteristic. 

Stretching or contusion of the nerves of the upper arm is characterized 
by anesthesia, loss of power, often by persistent and harassing neuritis, 
and by muscular atrophy. 

Contusion and Sprain of the Shoulder. — Contusion is due to direct force, 
usually a fall on the point of the shoulder. Sprain is usually caused 
by violent wrenching of the humerus upward or backward, or twisting 
inward. These injuries are characterized by severe pain, pronounced 
disability, tenderness at the point of direct bruise or capsular tear, 
and, in the case of sprain, late ecchymosis, often extensive, commonly 
appearing on the inner side of the arm. The ruptured capsule may 
tear away a fragment of bone with it. 

The distinction from luxation is made by finding the head of the 
humerus in its normal position; from fracture by the absence of char- 



THE ARM AND SHOULDER 



419 



acteristic symptoms of this affection. The motions of abduction and 
outward rotation are usually most painful and are sharply limited. 
There may be blood effusion into the joint, which, if extensive, may be 
palpated. The reactive inflammation often becomes chronic in the 
middle-aged and elderly, causing deltoid atrophy, weeks or months of 
harassing pain, periarthritic thickening and contracture, and partial or 
complete fixation of the joint. 

Injuries of the shoulder-joint depart from the rule that persistent 
disability and tenderness following trauma justify the assumption that 
there has been a lesion of the bone. Even though clear a;-ray pictures 
fail to show such lesion, the ultimate prognosis of contusion or sprain of 
the shoulder must be guarded. This disability is often attributable 
to a chronic post-traumatic inflammation of the subdeltoid bursa, 
resulting in adhesion of its walls and obliteration of its cavity. 



Fig. 287 




Paralysis of the serratus magnus (long thoracic nerve). Arm cannot be carried beyond a right 
angle with the long axis of the body. Posterior border of the scapula prominent. 



Fractures. — Fractures of the shaft of the humerus (frequent), trans- 
verse, oblique, or spiral, in the latter case at times comminuted, are 
usually due to direct force, are simple, complete, and exhibit all the 
characteristic features of the injury. A complicating lesion to the 
musculospiral nerve at the time, or later as the result of callus formation, 



420 



THE UPPER EXTREMITY 



is frequently noted. Muscular interposition, preventing crepitus and 
later causing non-union, is occasionally observed in these fractures. 

Fractures of the upper extremity of the humerus may involve the 
head of the bone or may pass through the anatomical neck. In either 
case the injury is intracapsular. They may pass through the tuber- 



FiG. 2881 



Fig. 289 





Fig. 288. — Oblique fracture through middle portion of shaft, in an adult male. 

Fig. 289. — Fracture at middle of shaft, in an adult female. Anterolateral view shows line slightly 
oblique, marked displacement, and complete over-riding with considerable shortening, the lower 
fragment being anterior. Clinical diagnosis of fracture easy, but x-rays important for determining 
displacement. 



1 Figs. 288 to 295. Fractures of the shaft of the humerus. Outline drawings from radiographs 
by Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; patients referred 
from services of Drs. White and Siter, and private cases of Dr. Pancoast. 



THE ARM AND SHOULDER 



421 



Fig. 290 



Fig. 291 





Fig. 290. — Longitudinal fracture involving middle third of shaft, in an adult male. Occurred 
while throwing a baseball. (Unusual but not uncommon cause of such fractures.) An important 
feature is the fact that the anteroposterior view (usually the only one that can be made because of 
the form of dressing), while showing the fracture, gave the impression of perfect apposition. The 
lateral view here represented (taken with dressing removed) reveals a complete separation. Under 
such circumstances xmion would either not take place or would be much delayed. Clinical diagnosis 
of fracture not difficult, but x-rays very important for determination of deformity. 

Fig. 291. — Transverse fracture about junction of lower and middle thirds of shaft, in a boy, aged 
nine years. Anteroposterior \'iew indicates apparent good approximation. (Compare with 
Fig. 292.) 



osities or beneath them (surgical neck), may involve the greater or 
lesser tuberosity, or may appear as comminuted breaks representing 
combinations of these forms. They are observed most frequently 
in old age or youth. 

Fracture of the head of the humerus, usually fissured and without 
displacement, is characterized by disability, pain, and tenderness, best 



422 



THE UPPER EXTREMITY 



Fig. 292 



Fig. 293 





Fig. 292. — Lateral view of same case as Fig. 291, shows almost complete forward displacement 
of lower fragment. Clinical diagnosis of fracture easy, but importance of careful a:-ray examination 
is apparent. 

Fig. 293.— Comminuted fracture in lower third of shaft, in a girl, aged eleven years, resulting 
from a fall. Lateral view after reduction shows good approximation. 



elicited by deep axillary palpation and by jarring the head of the 
humerus against the articular surface of the scapula by sudden pressure 
against the abducted and flexed elbow. It can be positively diagnos- 
ticated only by the x-rays. 

This is also true of fracture of the anatomical neck (above the tuber- 
osities). The small intracapsular fragment may be completely reversed. 
The joint is imduly lax, the disability is absolute, and crepitus may 
be elicited by abduction, traction, and rotation of the humerus, the 
fingers of the examining hand being pressed deep in the axilla. In 
case of impaction, crepitus will be absent and all the other symptoms 
will be less marked. 

Fracture through the tuberosities, epiphyseal in young people (before 
the age of twenty), often impacted in older ones, results from direct 
violence. 

Epiphyseal fracture without deformity and impacted fracture are 
impossible to diagnosticate without the a;-rays. Deformity, if it exists, is 
usually due to a forward and upward displacement of the upper end 
of the lower fragment, which may be felt beneath the coracoid process. 
The presence of the head in its normal position, its failure to rotate 
with the shoulder, the preservation of the shoulder rotundity, preter- 
natural mobility, and soft or grating crepitus, exclude luxation; more- 



THE ARM AND SHOULDEH 423 

Fig. 294 Fig. 295 



Fig. 294. — Multiple fracture in lower third of hiimerus, and compound, in a sailor, aged twenty- 
two years, resulting from a fall from a great height. The lateral view here represented was the 
only one possible at the first examination, and indicates two separate fractures of the shaft, with 
complete separation between upper and middle fragments (see Fig. 295). 

Fig. 295.— Same case as Fig. 294, anterolateral view obtained after a change in form of dressing 
following a partial reduction. Indicates an additional longitudinal fracture of the lower fragment, 
splitting the condyles apart. This view fails, however, to show the break between the middle and 
lower fragments which is distinctly evident in the direct lateral view. 



over, the fracture occurs at a time of life when dislocation is rare. From 
fractures of the surgical neck the diagnosis can be made only by the 
ic-rays. 

Fracture of the surgical neck (beneath the tuberosities) is the one 
most frequently found in the upper extremity of the humerus. It is 
especially common in elderly people because of senile atrophy. The 
upper end of the lower fragment projects upward and forward. 
Characteristic fracture symptoms are usually present. 

Distinction from luxation is made by the finding of the head of the 



424 



THE UPPER EXTREMITY 



bone in its normal position and its failure to rotate with the shaft of 
the humerus. 

Impacted fracture is suggested if, with disability and pronounced 
pain, there is marked shortening as contrasted with the sound side, 
the measurements being taken from the acromial process to the external 
condyle. When there is doubt, the a;-ray is needful for diagnosis. 

Fractures of the greater tuberosity are usually complicated by other 
injuries, particularly by luxation. They may be partial without dis- 
placement, the injury being suggested by persistent localized tenderness 
and pain, the latter markedly increased by voluntary efforts at external 
rotation. 

Isolated fracture with complete separation (rare) is characterized by 
free or even exaggerated rotation, forward subluxation of the humeral 
head, and possibly the detection of the movable fragment which is 
dragged down and out, broadening the shoulder and making the 
acromion unduly prominent. The long head of the biceps may be 
interposed between the fragments. When the fracture complicates 
luxation, it may interfere with reduction, and when the latter is accom- 
plished, it permits easy recurrence. 

Fracture of the lesser tuberosity (rare) is suggested by inability to 
actively rotate the arm inward and persistent localized pain and 

Fig. 2961 




Fracture of the anatomical neck, caused by direct violence. Patient an adult male. 



1 Figs. 296 to 308. Fractures of the upper portion of the humerus. Outline drawings from 
radiographs by Dr. H. K. Pancoast in collection of University Hospital a;-ray Laboratory; cases 
referred by or from services of Drs. White, Frazier, Carnett, Young, and Spellissy, from dispensaries, 
and private cases of Dr. Pancoast. 



THE ARM AND SHOULDER 

Fig. 297 



425 




A complicated injury of the shoiilder comprising the following distinct fractures: (a) Fracture 
through the surgical neck; (b) a longitudinal fracture extending downward through the head 
to the line of the previous one, and splitting the upper portion of the bone lengthwise into two 
parts; (c) a fracture of the portion of the anatomical neck represented in one of these fragments; 
and (d) a fracture of the acromion process with wide separation of the fragment from its clavicular 
attachments. Such injvu-ies are the result of unusually severe violence, and in this instance the 
patient, a male, aged twenty-foiu- years, was struck by a train. 

Fig. 298 




Fracture of the greater tuberosity of the humerus, without separation of the fragment. 
Patient a female, aged fifty-seven years. 



426 



THE UPPER EXTREMITY 

Fig. 299 




4 



\ 



Fracture of the greater tuberosity, with wide separation and displacement^^ inward of the 
fragment. This fracture compHcated a dislocation which was reduced before the radiograph 
was made. The x-rays show it to be not an uncommon complication of shoulder dislocations. 
Patient a male, aged eighty-six years. 



Fig. 300 



Fig. 301 




Fig. 300. — Fracture of the greater tu- 
berosity and incomplete fracture of the 
anatomical neck resulting from direct vio- 
lence by a blow of a fist. Patient an adult 
female. 

Fig. 301. — Fracture of the greater tu- 
berosity and incomplete fracture of the 
surgical neck resulting from direct violence 
by striking the shoulder during a fall on 
the ice. Patient a female, aged thirty-six 
years. 



THE ARM AND SHOULDER 



427 



tenderness. Crepitus and mobility may be elicited. The rr-rays may 
be needful for diagnosis, especially when it is a complication of dis- 
placement. 



Fig. 302 




Old fracture of the greater tuberosity and the surgical neck. This injury was the result 
of an automobile accident. No diagnosis of fracture was made at the time, and the patient 
was treated for a contusion of the shoulder. The radiograph here represented was made when she 
consulted a surgeon later for an ankylosis of the joint. Although union was complete and the 
fragments were in fairly good apposition, there was firm fixation of the joint. Patient an adult 
female. 

Fig. 303 




Impacted fracture of the surgical neck with comminution of the upper fragment of the head, 
which is apparently split apart by the entering wedge of the shaft. Patient a male, aged forty- 
one years. 



428 



THE UPPER EXTREMITY 
Fig. 304 




I 



Fracture of the surgical neck, which, with the accompanying typical deformity, presents an 
appearance conforming with the usual graphic description of this injury. The upper fragment 
is rotated outward, while the lower one is displaced upward and inward. The nature of this 
fracture and the direction of the line readily explain why the displacement shown had resisted 
repeated attempts at correction. Patient a female, aged fifty-six years. 



Fig. 305 




Fracture of the surgical neck in a child, aged ten years. In children the injury in this part of 
the bone may be either an epiphyseal separation or a fracture of the surgical neck below the line, 
depending largely upon the nature and the direction of the force. 



THE ARM AND SHOULDER 



429 



Fig. 306 




Fracture oE the surgical neck, probably complete, but in some respects resembling an incom- 
plete fracture. The injury was due to direct violence. There were no cardinal symptoms of 
tracture in this case, pain aggravated by rotation and local tenderness being the only physical 
signs directly referable to a break. Patient an adult male. 

Fig. 307 




Fracture of the shaft just below the surgical neck. Although complete, the only signs directly 
referable to the fracture in this case were pain and local tenderness, and an exact diagnosis was 
dependent solely upon the x-ray examination. Patient an adult male. 



430 



THE UPPER EXTREMITY 
Fig. 308 




Subcoracoid dislocation of the shoulder, complicated by fracture of the tuberosities of the 
humerus, in an adult female. Clinical diagnosis of dislocation not difficult, but of fracture 
uncertain in respect to exact seat. 

Fracture of the Scapula. — Fracture of the scapula is rare. These 
fractures may be articular, a portion of the joint surface being chipped 

Fig. 3091 




Fracture of the acromion process. Patient an adult male. 

1 Figs. 309 to 313. Fractures of the scapula. Outline drawings from radiographs by Dr. H. K. 
Pancoast in collection of University Hospital a;-ray Laboratory; patients referred by or from 
services of Drs. Frazier, Fussell, and White, from dispensaries, and private cases of Dr. Pancoast. 



THE ARM AND SHOULDER 
Fig. 310 



431 




Fracture of the coracoid process. The cardinal symptoms of fracture were absent in this 
case, the moderate degree of downward and outward displacement preventing crepitus. The 
condition was strongly suspected clinically, but an exact diagnosis could not be made. This 
fracture is not only difficult to diagnosticate clinically, but is very easily overlooked radiographically 
as well. Patient a male, aged fifty-seven years. 



Fig. 311 




Old fracture of the lower portion of the lip of the glenoid cavity, with probably more or less 
union of the somewhat displaced fragment, resulting in partial ankylosis of the shoulder-joint. 
Patient a female, aged sixty-two years. 

off usually as a complication of luxation, or the whole joint surface 
being avulsed (anatomical neck). They may pass through the surgical 
neck, the lesser fragment then including the coracoid process, through 
the acromion process, the coracoid process, the spine, or any part of 
the bodv of the bone. 



432 



THE UPPER EXTREMITY 
Fig. 312 




1 



i 



Fracture of the surgical neck of the scapula. The line of fracture can be seen only through 
the thick outer border of the bone, its probable course upward toward the suprascapular notch 
being concealed by the thickened portions of bone forming the root of the coracoid and the 
spine, and possibly also by some overlapping of the separated fragment. Patient a male, aged 
forty years. 



i 




A complicated injury of the shoulder comprising four distinct fractures: (a) The surgical 
neck of the scapula; (6) the lower portion of the lip of the glenoid cavity; (c) the shaft of the 
humerus just below the surgical neck; {d) the greater tuberosity of the humerus, the fragment of 
which is considerably displaced downward and inward. Patient an adult male. 

Fractures of the articular surface, usually limited to small parts, 
or stellate, exceptionally involving the entire articular surface, are diag- 
nosticated by tenderness, disability, crepitus, and the o^-rays. The last 



THE ARM AND SHOULDER 433 

form presents features much like those of fracture of the surgical neck, 
except that the coracoid process does not move with the humerus and 
lesser fragment. 

Fracture of the surgical neck, usually from direct violence, is char- 
acterized by dropping and abduction of the arm, flat shoulder with 
prominent acromion, free passive movement, and absolute disability. 
There is lengthening as measured from the acromion to the external 
condyle. Deep axillary palpation may detect the fragment, and usually 
gives crepitus if the humerus is pushed up and rotated. The coracoid 
process follows the motions of the humerus. 

The easy, grating reduction of deformity, by pushing up the humerus, 
and its prompt recurrence on removal of pressure, distinguish this 
lesion from luxation. 

Fractures of the acromion process are in youth epiphyseal, and are 
complicated at times by dislocation of the outer end of the clavicle. 
These fractures are characterized by marked disability and tenderness, 
crepitus, and slight mobility, best elicited by alternately pulling and 
pushing the abducted humerus and direct manipulation. Usually 
there is no deformity. 

The a;-rays may be deceptive since the acromial epiphysis may remain 
permanently separated from the scapular spine by a cartilaginous 
plate. 

Fractures of the coracoid process (rare) result from direct trauma 
or muscular action. They are characterized by disability, localized 
tenderness, swelling, and crepitus; if the ligamentous attachments are 
torn away, downward displacement. Localized tenderness, mobility, 
and crepitus may be detected by deep, direct palpation. 

The diagnosis of this affection is theoretical rather than practical, 
except with the aid of the ic-rays. 

Fractures of the spine, body, or angles of the scapula, due to direct force, 
are characterized by pain, swelling, and usually but little deformity. 
The detection of mobility and crepitus is diagnostic, and, if the fracture 
be complete, is easily accomplished by grasping and manipulating the 
bone. The traumatic inflammation of the subscapular bursa may 
give crepitus, pain, and disability, which should not be mistaken for 
fracture. 

Fractures of the Clavicle. — Fractures of the older third of the clavicle, 
if within the limits of the coracoclavicular or acromioclavicular liga- 
ments, are attended with localized pain and tenderness, and disability, 
but with displacement so slight as to escape detection on examination, 
though the bone throughout its whole extent is subcutaneous. If the 
break be between these ligamentous attachments, the displacement is 
usually obvious. It is distinguished from luxation by the angularity 
of the projecting fragment and crepitus. 

Fractures of the middle third, usually at the junction of the middle and 

outer third, may be transverse or oblique. They occur most frequently 

in children as the result of a fall on the hand or shoulder, and are 

often incomplete. The complete fracture is characterized by deformity 

28 



434 



THE UPPER EXTREMITY 



which can be seen and felt, mobility and crepitus, detected by grasping 
and manipulating the fragments or by raising, depressing, and abducting 
the shoulder while the seat of injury is palpated. There is late (days) 
ecchymosis over the seat of injury. In the case of children there may 
be surprisingly little loss of function. 

The incomplete fracture, occurring usually in children, will be char- 
acterized by sharply localized tenderness, deformity, late ecchymosis 
(days), and usually pronounced disability, the arm hanging unused at 



Fig. 3141 




Example of the most common type of fracture of the clavicle, at about the junction of the 
middle and outer thirds, showing also the typical deformity — dropping of the outer fragment with 
the shoulder, relative or actual upward displacement of the outer end of the inner portion, and over- 
riding with shortening. Patient, a male, aged thirteen years. 

Fig. 315 




A typical example of the so-called "green-stick," or incomplete, fracture occurring at one of its 
most frequent seats — the jimction of the outer and middle thirds of the clavicle. Patient a boy, 
aged eight years. 



1 Figs. 314 to 316. Fractures of the clavicle. Outline drawings from radiographs by Dr. H. K. 
Pancoast in collection of University Hospital x-ray Laboratory; patients referred from dispensary 
service. 



THE ARM AND SHOULDER 

Fig. 316 



435 




Comminuted fracture of the acromial end of the clavicle. The injury resulted from the 
patieat, an adult male, "taking a header" from a bicycle and striking on the shoulder. 

the side. At times there is no disability, the fracture not being suspected 
until ecchymosis and, later (a week), callus formation suggest the nature 
of the lesion. 

Luxations of the Shoulder-joint.— Dislocation of the head of the humerus 
from the glenoid cavity, the commonest of all luxations, is observed 
chiefly in vigorous adult males. 

It is rare in children, the traumatic bone lesions in them appearing 
as fractured clavicle or epiphyseal separation of the humerus. In the 
elderly, fractures of the surgical neck of the humerus can be expected. 

The usual cause of luxation is direct or indirect violence; excep- 
tionally it has been due to muscular action, as from throwing efforts. 

The forward dislocations are the subcoracoid and subclavicular. 
The downward displacement is subglenoid; the backward, subacromial 
or subspinous. 

Common complications are tearing away of muscular attachments, 
particularly those of the subscapularis and the supra- and infraspinatus, 
and fracture of the articular process of the scapula or shaft or tuberosities 
of the humerus. The commonest complicating fractures are those of 
the surgical neck and the great tuberosity of the humerus. 

The symptoms of luxation are pain, complete disability, elastic 
fixation of the arm, usually in slight abduction, angularity due to the 
prominence of the acromion and the flattening of the deltoid bulge 
beneath it. There is a depression felt beneath the anterior portion of 
the acromion border where the greater tuberosity should normally form 
a bulging projection (the point of the shoulder). The displaced head 
of the bone is felt in its abnormal position. The elbow stands out 
from the side and efforts to bring it in contact with the chest wall demon- 



436 



THE UPPER EXTREMITY 

Fig. 317 



^^s^''^ ■ ''''*il^Hii^^ 






\ 



Subcoracoid luxation of right hximerus. Several months old. Angled shoulder. Increased 
width measured from top of shoulder to lower border of anterior axillary fold. Arm carried slightly 
from side. A plane surface can be made to touch the external condyle and the outer acromial 
border. Forearm flexed. 

Fin. 318 




Recent subcoracoid luxation of humerus. The characteristic features shown at Fig. 317 somewhat 

obscured by swelling. 



THE ARM AND SHOULDER 437 

strate an elastic resistance, nor, even in the subclavicular displacement, 
can the hand of the injured side be carried to the sound shoulder and 
the elbow be brought in contact with the chest wall. This last test 
fails when the capsule and muscular attachments of the humerus have 
been extensively torn, and in enormously fat people. 

In all cases there is an increase in the circumference of the shoulder 
and a departure from normal in the direction of the long axis of the 
humerus as contrasted with that of the sound side. With the arm 
rotated inward and pressed as close to the side as is possible, a plane 
surface can be made to touch the external epicondyle and the anterior 
portion of the outer margin of the acromion. This is impossible unless 
the greater tuberosity is displaced. 

The subglenoid luxation is characterized by the ease with which the 
head of the bone can be felt by axillary palpation and by pronounced 
abduction which exceptionally may carry and hold the elbow out so 
far that the arm makes almost a right angle with the long axis of 
the body. In this form of luxation there is sometimes lengthening as 
measured from the acromion process to the external condyle. The sub- 
coracoid and subclavicular displacements are characterized by finding 
the head of the bone in the position indicated by the name. In both 
the elbow is carried outward and backward. 

The backward luxations, subacromial or subspinous, are rare and char- 
acterized by prominence of the acromial process, often of the coracoid, 
and the presence of the rounded tumor made by the head of the humerus, 
either beneath the posterior border of the acromion, where there is 
normally a depression, or the spine of the scapula. Unless there be 
extensive muscular rupture, the arm is fixed in a position of adduction 
and internal rotation. 

The diagnosis of complicating fractures, if these involve the shaft 
of the bone, is dependent upon finding the glenoid cavity empty, the 
head of the bone in its abnormal position, and preternatural mobility 
and crepitus elicited by direct palpation and adduction, abduction, and 
rotation of the humerus. If the surgical neck be broken, the head 
and tuberosities will not participate in passive movements of the shaft. 

Fracture of the glenoid cavity is suggested by crepitus on deep pal- 
pation and by difficulty of retention after reduction is accomplished. 

Fracture of the tuberosity and of the surgical neck of the scapula 
are likely to escape detection in the presence of the rapid and extensive 
swelling which follows dislocation, without the help of the a;-rays. 

Although the symptoms of dislocation of the shoulder-joint are 
fairly marked, determination of the presence or absence of this lesion 
may be difficult in fat, muscular subjects, since the examination is always 
painful. In case of doubt, examination should be conducted under 
full anesthesia, and, as is the case with all injuries about joints, the 
a:-rays should be used. 

The examination of a case of shoulder luxation should not be con- 
cluded until the surgeon has assured himself of the integrity of the 
neighboring vessels and nerves. 



438 



THE UPPER EXTREMITY 



If the circumflex nerve, winding around the surgical neck of the 
humerus and supplying the joint, the deltoid, and, by a cutaneous 
branch, the skin over the lower third of this muscle, be permanently 
injured, deltoid atrophy will follow. Anger states that such injury may 
be suspected if immediately following trauma there is anesthesia in the 
skin area supplied by this nerve. 

The axillary artery may be torn without immediate colossal hemor- 
rhage. Such complication should be at least considered if on first 
examination the radial or brachial pulse cannot be felt. 

Luxation of the Clavicle. — Either the outer or the inner extremity of 
the clavicle may be displaced, either by direct or indirect force. Dis- 
placement of the outer end is characterized by extreme pain and 
pronounced disability. Undue mobility and displacement are readily 
detected. Congenital eccentricity of conformation may lead to error 
in the case of the acromioclavicular joint. 



Fig. 319 




Seborrheic eczema of the axilla. (Hartzell.) 

Inflammatory Affections of the Arm and Shoulder. — Acute inflam- 
mation of the soft parts of the arm and shoulder conform to type in 
etiology and symptoms. 

Seborrheic eczema and tinea are fairly common in the axilla. 

This region is a common seat of follicular abscesses which develop 
successively in fresh crops, usually beginning as red, tender, shot-like 
skin nodules which shortly suppurate. They are extremely painful and, 
because of their position, cause disability. These abscesses may originate 
either in the sebaceous or the sudoriferous glands. In the latter case 
they are placed more deeply and are of larger size. 



THE ARM AND SHOULDER 



439 



At times these subcutaneous abscesses are the starting points of diffuse 
cellulitis and are accompanied by symptoms of profound septic absorp- 
tion. They are occasionally complicated by suppurating axillary 
glands. 

Abscesses beneath the deep fascia are usually of lymphatic origin, 
incident to infection of any of the areas draining into these glands; 
they may be secondary to osteomyelitis of any of the bones adjoining 
the axillary space or may be caused by a perforating pleurisy. They 
may reach huge proportions, burrowing widely beneath the pectorals 



Fig. 320 




Tinea of the axilla. (Hartzell.) 



and the clavicle. These burrowing abscesses cause profound systemic 
poisoning. The diagnosis is based on the diffuse swelling, fluctuation, 
surface edema, and constitutional symptoms of sepsis. 

Acute axillary adenitis, characterized by tender swollen axillary 
nodules, secondary to wounds of the hand, arm, shoulder, or side of 
the chest, usually undergoes resolution on proper drainage of the 
original focus of infection. 

Acute Suppurative Inflammation of the Subdeltoidean Bursa. — ^This is 
evidenced by obvious swelling, most pronounced in its beginning just 
below the margin of the anterior third of the acromion, associated 



440 THE UPPER EXTREMITY 

with extreme tenderness at this point, followed shortly by a swelling 
which completely obscures the point of the shoulder, edema of the skin, 
and marked limitation of the motions of the humerus in the outward 
and forward direction. It is usually a manifestation of systemic infec- 
tion; very exceptionally it follows traumatism. 

The diagnosis is based upon the position of swelling. Intra-articular 
effusions never form a projecting tumor at the point of the shoulder. On 
deep axillary palpation the joint is not tender, and only those motions 
are painful which directly affect the inflamed bursa. The constitutional 
symptoms are those of septic absorption. The x-rays indicate the 
position of the inflammation. 

Acute Osteomyelitis of the Humerus. — ^This is less common than is the 
case with the tibia or femur and usually attacks the upper extremity of 
the bone. Although the focus is situated at or near the epiphysis, the 
line of diaphyseal junction being extra-articular, the joint is usually 
spared, the abscess appearing externally. 

Diagnosis is based upon severe pain, localized tenderness on deep 
pressure, rapid edematous swelling of the soft parts, disability and 
constitutional signs of acute sepsis. Freedom of passive motion and 
absence of tenderness on direct palpation exclude arthritis of the shoulder. 
In young people, epiphyseal separation and subsequently marked im- 
pairment of bone growth are common sequelae. 

Multiple foci of infection throughout the shaft of the bone cause 
tenderness to deep pressure and marked edematous swelling of the 
entire arm, together with the symptoms of profound sepsis. They are 
followed by necrosis and the formation of sequestra. 

As in the other bones, the inflammation may subside without pro- 
ducing gross necrosis, or may continue indefinitely, in the chronic form 
producing great thickening of the bone accompanied by harassing pain 
and localized tenderness. 

Acute serous and serofibrinous arthritis may be secondary to trauma 
or periarticular inflammation (osteomyelitis, the infection not reach- 
ing the joint), but is usually a local expression of constitutional infec- 
tion (gonorrheal, rheumatic, typhoidal, pneumonic, influenzal, exan- 
thematous). It is characterized by severe pain, rapid in onset, and 
crippling in intensity, greatly aggravated by passive movement in any 
direction but particularly by that of abduction, limitation of the motions 
of the shoulder in all directions and tenderness on pressure best marked 
at first where the joint can be most nearly approached by the examining 
finger (axilla, bicipital groove). There is little appreciable swelling 
even on careful palpation. Indeed, an obvious swelling of the shoulder, 
except as the result of acute suppuration or of a long-standing disease, 
practically excludes the shoulder-joint as the seat of disease. 

Acute Suppurative Arthritis of the Shoulder. — This is secondary to an 
infected wound, osteomyelitis, or, rarely, general infection (pyemia, 
pneumonia, smallpox). It is characterized by intense pain, rapid and 
diffuse edematous swelling, total disability with joint fixation, and con- 
stitutional symptoms of profound sepsis. 



THE ARM AND SHOULDER 



441 



The early diagnosis should be made by aspiration and examination 
of the fluid. 

Chronic Inflammation of the Arm and Shoulder. — Syphilitic Myositis. 
— Syphilitic myositis of the biceps may develop in the secondary or the 
tertiary period of the disease. In the former case it is rapid in onset 
(days), is characterized by pain and stiffness on motion, by slight tender- 
ness and, possibly, diffuse swelling. It is usually considered rheumatic. 



Fig. 321 




Epithelioma in cicatrix. Extensive burn of arm and chest. Complete healing with adhesion 
between arm and chest. Epitheliomatous ulceration of cicatrix twelve months' duration. Slough- 
ing, bleeding ulcer with everted indurated edges. Edema of hand from venous and lymphatic 
obstruction. (Carnett.) 



In the tertiary form contracture of the muscle is the dominant 
symptom; the forearm becomes gradually flexed on the arm, nor can 
it be extended. The biceps, painful and tender at first, later, swollen, 
undergoes gradual atrophy. The triceps muscle is sometimes affected 
in the same way, the contracture then limiting flexion. 

This muscular contracture is in itself almost diagnostic of syphilis. 
It yields rapidly to constitutional treatment unless this has been post- 



442 THE UPPER EXTREMITY 

poned until muscular degeneration and permanent cicatricial con- 
tracture have taken place. 

Gumma and tuberculous abscess, noted in both the biceps and triceps 
muscle, can be distinguished from neoplasm in their early course only 
by operation. 

Inflammatory hyperplasia of the axillary glands, characterized by 
nodular, usually non-sensitive swellings, may follow infection or trau- 
matism of any of the areas drained into these glands. From the arm 
and hand, the lymph is received by that group which lies along the 
vessels; from the breast, thorax, and upper abdomen, by the group 
lying along the lower axillary border of the great pectoral muscle. 
The subscapular and subclavicular group drain the shoulder and back. 
These groups, however, freely intercommunicate. The pectoral and 
vascular groups are the ones chiefly involved in chronic inflammation 
of the breast or hand. 

Tuberculous adenitis, usually secondary to tuberculosis elsewhere, 
or associated with it, particularly with involvement of the glands of the 
neck, pursues the same course as that characteristic of tuberculous 
glands in general. 

Neuritis. — Neuritis, usually post-traumatic, at times ascending from 
a peripheral lesion, is characterized by extreme tenderness along the 
course of the nerve, loss of function, and muscular degeneration. 
Harassing pain referred along the course of the brachial plexus, partic- 
ularly in its ulnar distribution, relieved by posture and unattended by 
the characteristic features of neuritis is sometimes attributable to droop- 
ing shoulder and relaxed ligaments (Goldthwait). 

Bursitis. — ^There is at times developed an adventitious bursa on the 
inner surface of the serratus magnus muscle placed at either the upper 
or lower angle of the scapula. This, when chronically inflamed, may 
give rise, on motion, to an annoying grating without any other symp- 
toms. Or it may be associated with considerable pain. 

The diagnosis is based upon the seat of pain and grating and the 
dependence of these symptoms upon scapular movements. 

Acromial Bursitis. — Acromial bursitis due to repeated slight trauma, 
as from carrying weights on the shoulder, is characterized by a soft, 
smooth, fluctuating, dome-shaped tumor placed between the skin and 
the summit of the acromion process. The free mobility of the over- 
lying skin and absence of lobulation, distinguish this bursitis from 
lipoma. As the result of trauma, this chronic bursitis may become 
acutely suppurative. 

Suhdeltoidean Bursitis — The subdeltoid bursa lies between the under 
surface of the deltoid muscle and the acromial process (subacromial 
portion) and the upper surface of the supraspinatus tendon and the 
greater tuberosity of the humerus. 

The inflammation is usually fibrinous and adhesive in type, is post- 
traumatic, and is characterized by tenderness elicited by deep pressure 
against the greater tuberosity, just below the anterior third of the outer 
acromial border. There is pain, constant or recurrent and harassing. 



THE ARM AND SHOULDER 



443 



radiating along the outer surface of the arm, greatly aggravated by 
voluntary or passive movements of the humerus, either outward or 
forward, ultimately muscular atrophy and a subluxated, stiff joint. 

Exceptionally this chronic bursitis, when subject to repeated slight 
trauma, forms either a large hygroma or a hard, palpable tumor with 
cheese-like contents. 

Fig. 322 




^eltoidmusch 



Dissection of an injected subdeltoidean bursa. (Baer.) 



The diagnosis can be suspected from the position of the tumor, its 
sensitiveness, the distribution of the pain area, the character of the 
disability, and the rr-ray picture. It can be made surely only by 
incision and microscopic examination of the removed bursa. 

Tuberculous subdeltoidean bursitis is characterized by the almost 
painless formation of a soft tumor in the position of the bursa, which 



444 



THE UPPER EXTREMITY 

Fig. 323 




Chronic subdeltoidean bursitis. Both arms are abducted to their full extent. (Baer.) 

Fig. 324 





— 




1 


M 


I 


-J 


^^^^ 




^^^^■"-■•^^iiili^i^lBI 


1 


1 


^ 


A. 



Chronic traumatic subacromial bursitis. Duration, months. Pain and disability marked. 
Complete abduction still possible, but accomplished with much difficulty. When the arm is carried 
from the side as far as shown in the illustration, it is by a swinging motion of the shoulder rotated 
outward, after which it can be carried above ^he head. On bringing the arm down to the side, 
the motion is reversed. In many cases the complete abduction is impossible. 



THE ARM AND SHOULDER 



445 



on manipulation gives the crepitation or chain-like grating incident to 
the villous growth from its inner surface or the rice-like bodies it usually 
contains. In the absence of crepitation the affection simulates fatty 
tumor, but is much more rapid in growth. 

From sarcoma, it should be distinguished by operation, since a malig- 
nant tumor so placed as to suggest chronic bursitis cannot be distin- 
guished from this affection. 

Subcoracoid Bursitis. — The coracobrachial bursa lies between the tip 
of the coracoid process and the joint capsule overlying the lesser 
humeral tuberosity. Inflammation of the bursa is characterized by 
pain particularly marked in rotation and by limitation of the same 
motion. There may be a constant or recurring pain often referred 
down the arm, and pronounced disability 



Fig. 3.25 




Chronic travunatic subacromial bursitis. The arm has been rotated outward and is being carried up 



Chronic Inflammation of the Bones and Joints of the Arm and 
Shoulder. — Chronic Osteomyelitis of the Humerus. — This may be sequent 
to an acute attack which subsides without producing gross necrosis. The 
inflammation continues indefinitely, producing great thickening of the 
bone, accompanied by harassing pain and localized tenderness. There 
may be a central sequestrum without pus. 

Tuberculosis of the Humerus. — ^Tuberculosis of the humerus rarely 
affects the shaft of the bone. Its presence is suggested by pain and 
localized tenderness. 

Tuberculosis of the upper epiphysis is less prone to involve the joint 
than is the affection when it attacks the lower epiphysis. Deep-seated 
pain, persistent tenderness, and disinclination to use the part, these 
symptoms gradually (weeks or months) growing worse and finally 
supplemented by tumor, softening, and the formation of sinuses leading 
to dead bone, are characteristic features. 



446 



THE UPPER EXTREMITY 



The diagnosis in the early stages of the affection will be suggested 
by a tuberculous family history and the presence elsewhere of lesions 
of the disease. It should be made by the or-rays before visible or pal- 
pable tumor formation; by incision as soon as a bone swelling can be 
detected. 

Gummatous Osteitis. — Gummatous osteitis of the humerus, charac- 
terized by local tenderness, often extreme pain and tumor formation, 
can be distinguished in its early stage from tuberculosis or malignant 
growth only by a suggestive history, associated with other more char- 
acteristic lesions and the prompt effect of specific treatment. 

Both syphilitic and tuberculous osteitis attack the scapula. Each 
affection develops according to type. 

The inner extremity of the clavicle is a favorite seat for gumma. 



Fig. 326 




Gumma of the sternal end of the clavicle. Tertiary period (years). Painless indurated growth 
from bone with central softening. Duration, one week. 



Chronic Arthritis of the Shoulder. — Chronic arthritis of the shoulder 
is usually traumatic, often toxic or infectious (rheumatoid arthritis, 
arthritis deformans), exceptionally neuropathic (syringomyelia and 
tabes). 

Traumatic chronic arthritis may follow severe injury, being then 
incident to bone and capsular lesions which even after recovery leave 
the joint so mechanically altered that ordinary use represents a con- 
stantly recurring trauma; or it may be the result of long-continued 
overuse, as in the case of laborers. It is an affection of old age, char- 
acterized by deformities typical of rheumatoid arthritis or osteoarthritis. 
Pain, weakness, muscular atrophy, subluxation, and limitation of 



THE ARM AND SHOULDER 447 

motion, together with grating crepitus, are present. Complete ankylosis 
is rare. 

Tuberculous Arthritis of the Shoulder. — This is rare as compared to 
the frequency of the inflammation in other large joints. It exhibits 
a predilection for that form of the affection characterized as dry caries, 
the bone being softened and abraded, often without the formation of 
a sinus discharging externally. 

The affection is characterized by pain, intermittent at first, limita- 
tion of joint movement with muscular atrophy, and tenderness on 
palpation of the head of the bone in the axilla or in the bicipital groove 
to the inner side of the greater tuberosity. As the head of the hiunerus 
disappears by absorption, the acromion projects sharply. Periarticular 
swelling may be slight or may be pronounced. 

The early diagnosis of joint involvement is suggested by limitation 
of motion in all directions, tenderness elicited by direct palpation and 
by upward jars of the elbow, muscular atrophy, and the skiagram. 
These symptoms will distinguish a caries sicca from malignant growth, 
which is always in the beginning extra-articular. 

The fungous form of arthritis of the shoulder corresponds to type 
as seen in other joints. The bursse are very commonly involved. 

Neuropathic Arthritis of the Shoulder. — Neuropathic arthritis of the 
shoulder, secondary to syringomyelia or tabes, is characterized often by 
extraordinary bone deformity, absence of pain, and function limited 
only by the obstruction to movement offered by the bony outgrowths. 

Neurosis of the Shoulder-Joint. — Neurosis of the shoulder-joint, when 
it occurs in an hysterical female skilled in the ways of doctors, is the 
most difficult of all the affections of this region to diagnosticate. 

Tumors of the Arm and Shoulder. — The tumors of the skin and 
subcutaneous fascia of the arm are those common to these tissues. 
Lipoma is, perhaps, the commonest tumor. In fat people, painful 
fibrolipomata are at times observed. 

Indurations of bony hardness are observed both in the brachialis 
anticus and the deltoid, incident to repeated trauma. They are tender 
on pressure, but occasion little pain or disability aside from the mechani- 
cal one, nor do they exhibit any tendency toward growth. 

Sarcoma of the muscles cannot be distinguished as such from tuber- 
culous abscess or gumma at a time when this is profitable, except by 
excision. 

Fibroma. — Fibroma has a peculiar predilection for the nerve trunks 
of the arm. It is characterized by a hard, fusiform, painful, and tender 
tumor in the course of the nerve, laterally mobile, but not in the long 
axis of the nerve, and causing sensory, sometimes motor, disturb- 
ance in regions supplied by the involved nerve. It is distinguished 
from myxoma or sarcoma of the nerve trunks (malignant neuroma) 
by its slow growth. Its position on the nerve is characteristic. It 
should be diagnosticated by the microscope before it is unmistak- 
ably malignant. 



448 THE UPPER EXTREMITY 

Lipoma. — Lipoma is the commonest tumor about the shoulder. It 
is slow in growth, subdermal, soft distinctly lobulated, and adherent 
to the skin. Its lobulation and skm attachments distinguish it from 
a supra-acromial chronic bursitis. Even when placed beneath the 
fascia, diagnosis is difficult only in its early course when, by pressure 
on nerves, the lipoma may produce pains radiating down the arms 
and distinct muscular weakness. Diagnosis then can be made only 
by incision. 

Lipoma is common in the axilla, at times associated with angioma. 

An aberrant mammary gland may occur in the axilla, closely simu- 
lating fatty tumor. 

Osteoma. — Exostoses as the after result of traumatism, or as a local 
manifestation of a general process, are observed on the humerus; they 
are characterized by indolence, painlessness, bony hardness, and slow 
growth (years). The same may be said of chondromata and cysts. 
The latter, when they reach moderate size, are attended by the 
crackling sensation characteristic of the well-developed myeloid sar- 
coma. Nor can the differential diagnosis be made except by microscopic 
examination. 

Sarcoma. — Sarcoma is the usual tumor of the deltoid and of the muscles 
surrounding the shoulder-joint. In its full development the diagnosis 
is unmistakable; in its early stage, its nature is suspected on the basis 
of probability and because of rapid growth. Diagnosis is made by 
excision and microscopic examination. 

Sarcoma originating from any of the structures of the axilla, par- 
ticularly the lymph glands and the nerve sheaths, exhibits its ordinary 
characteristics, i. e., the rapid growth of a round, sharply outlined, 
solid tumor. The early diagnosis from inflammatory hyperplasia of 
a lymphatic gland or tuberculous adenitis is based on the causeless- 
ness of the sarcoma, rapidity of growth and, later, on the size of the 
tumor. It should be made by early excision. 

Cavernous Angioma. — Cavernous angioma may sometimes suggest 
aneurysm, but is differentiated from this affection by the obvious skin 
involvement, by the absence of typical expansile pulsation and bruit, 
and by the slight effect produced upon it by pressure upon the sub- 
clavian artery. 

Lymphangioma. — Lymphangioma forms a cystic tumor in the axilla 
of infants which in its development passes up beneath the pectoralis' 
.minor and clavicle, and presents in the neck, forming a bilocular growth. 
Its characteristics are those of the same tumor as observed in the 
neck. Bleeding into such a cyst is the usual cause of non-traumatic 
hematoma. 

Carcinoma. — Carcinomatous glands of the axilla are secondary to 
cancer of the area from which the lymph is drained, usually the breast. 
In their early stage they cannot be distinguished from glands enlarged 
by inflammatory hyperplasia. 

Tumors of the humerus are commonest about the upper epiphysis. 
They are usually sarcomatous. In the early stage they are character- 



THE ARM AND SHOULDER 



449 



ized by persistent bone pain and localized tenderness; later by swelling, 
which, if allowed to develop, becomes entirely characteristic. If the 
growth is rapid, there is fever and toxic anemia. 



Fig. 327 




Metastatic carcinoma of humerus. Pathological fractiire. Operation for cancer of breast two 
years previously. Metastasis present in liver. (Carnett.) 

There are no characteristic features which early distinguish these 
tumors from tuberculous or syphilitic osteitis or osteomyelitis. The 
29 



450 



THE UPPER EXTREMITY 



diagnosis must be made by incision guided by a;-ray pictures and 
microscopic examination. In the later stage of these growths, rapid 



Fig. 328 




Metastatic carcinoma of humerus. Primary in breast. Multiple foci in humerus. First symptom 
observed was fracture on turning patient in bed. (Carnett.) 



increase of size, the destruction of bone substance, surface vascularity 
and discoloration, metastases, and cachexia enable the diagnosis to 
be formulated. 



CHAPTER XV. 

THE THORAX. 

Congenital malformations, such as those due to absence or deficient 
development of the pectoral muscles, of the sternum, or the ribs, are 
obvious to inspection and palpation. A funnel-like depression of the 
lower part of the sternum is frequently seen and occasions no symptoms. 
The asymmetry due to rickets is expressed in the form of pigeon-breast, 
the beading of the ribs, so characteristic in infancy, later disappearing. 



Fig. 329 



Pylorus opposite 
the 8th cartilage 
one inch to right 
of median line. 

Gall bladder op- 
posite tip of the 
9th costal car lilage. 




Tip of xiphoid cartilage. 

Median line (linea alba). 

Rectus muscle. 

Linea semilunaris. 

Lower edge of stomach. 

Lower edge of t rans. col . 
Umbilicus bet.Sd and 4th 

lumbar vertebrse 
Top oi crest of ilium 

Anterior superior spine. 

Poupart's ligament. 
Inter, abdominal ring. 
Femoral artery. 
Exter. abdominal ring 
Spine of pubis. 
Saphenous opening. 



Surface markings of the thorax and abdomen. (G. G. Davis.) 

Aneurysm or intrathoracic tumor may cause a local bulging even though 
it be not directly in contact with the chest wall. The widened inter- 
costal spaces and bulging ribs of recent pleural exudates, the deformity 
of the later stages, and the thoracic growth perversions of Pott's disease 
or spinal curvature are well-recognized features of the underlying 
lesions. 



452 



THE THORAX 



Acute Cellulitis. — Acute cellulitis incident to trauma, follicular abscess, 
osteomyelitis, and periadenitis, secondary to peripheral infection, occur- 
ring at times without demonstrable cause, are characterized by the 
constitutional symptoms of profound sepsis. There is often diffuse 
tenderness and inspiratory pain which closely simulates that due to 
pleurisy. Endocarditis and septic bronchopneumonia are common 
complications. 

The diagnosis of this fortunately rare condition is based on the local 
seat of tenderness, the profound constitutional symptoms, with the 
absence, at least in the early stage, of local signs of pleural involvement. 
Later, skin edema and fluctuation are characteristic of suppuration and 
indicate its seat. 

Fig. 330 




Cold abscess of the cLest wall (tuberculous osteitis). Puiniess, obscurely fluctuating, made tense 
by"coughing effort. Overlying""skin normal and non-adherent. 



Cold Abscess. — Cold abscess of the chest wall may be of sternal, 
costal, vertebral, pleural, or mediastinal origin. There is formed a 
fluctuating tumor which may exhibit impulse on coughing and which 
may pulsate. 

The chest wall abscess of chronic vertebral osteomyelitis travels 
forward between the ribs; the symptoms of Pott's disease are usually 
well marked. 

The abscess of sternal origin points over the bone or close to it; the 
same is true of the cold abscess of the anterior mediastinum. One 
originating in the posterior mediastinum may point along the ribs 



TRAUMATISM OF THE CHEST 453 

or above the clavicle. If of costal origin (tuberculous, post-typhoidal), 
the abscess commonly points near its seat of origin, though it may burrow 
widely. If from the pleura, the associated signs of an empyema are 
readily elicited. 

In some instances cold abscesses either in the intercostal space or 
in the dorsal region have no connection with bone, the original focus 
of infection probably having healed. 

The diagnosis of cold abscess, which may be of large size when first 
seen, would be suggested by distinct fluctuation. The resemblance to 
lipoma may be so close as to require operation for differential diagnosis. 

The tumor incident to bone erosion and surface projection of an 
aortic aneurysm may present the characteristics of cold abscess. 

Traumatism of the Chest. — Concussion. — Concussion of the chest, 
by which is meant the effect produced by a jarring blow not sufficiently 
violent to produce demonstrable lesions of the thoracic viscera, is evidenced 
by the symptoms of shock and may be immediately fatal. It is not 
infrequently attended by dyspnea so pronounced as to occasion cyanosis, 
the short, irregular, hurried, painful breathing being characteristic. 
This condition can be recognized as one independent of gross internal 
lesion only by a consideration of the relatively slight trauma, at times 
by a knowledge of the patient's hypersensitiveness to physical impressions, 
and usually by the rapid (minutes, hours) improvement of the symptoms. 

Spasmodic stricture of the esophagus is an occasional sequel of chest 
concussion. 

Contusion of the Chest. — Contusion of the chest is of importance when 
complicated by fracture or displacement of the bones, lesions of the 
contained viscera, or rupture of the diaphragm. Fracture and luxation 
are readily recognized. 

Visceral lesions will be characterized by shock, and bleeding evidenced 
by constitutional symptoms of hemorrhage. 

Diaphragmatic rupture will be shown by profound and persistent 
dyspnea, displacement of the heart, and tympany and gurgling over 
the seat of the displaced stomach. Rupture of the lung will be 
suggested by hemothorax or coughing up of blood, emphysema appear- 
ing first at the base of the neck if interstitial, or in the thoracic wall 
if incident to lung wound by complicating fracture. 

Wounds of the Chest. — Wounds of the chest are of importance in accord- 
ance with the extent to which the contained viscera are involved. Injury 
of the internal mammary or the intercostal artery may be followed by 
hemothorax and the constitutional signs of progressive hemorrhage. 
There is nearly always an associated external bleeding from the wound. 

Wound of the lung is characterized by shock, harassing cough which 
usually brings up frothy blood, dyspnea, often severe pain which 
may be referred to the abdomen, hemothorax, and pneumothorax. 
If the wound be a puncture or inflicted by a small caliber weapon all 
these symptoms may be absent. 

Pneumothorax developing in the presence of a parietal wound mechan- 
ically closed against the entrance of air is a convincing sign. 



#4 ^HE THORAX 

Diagnosis as to the seat of continued bleeding, if this be of neither inter- 
costal nor internal mammary origin, must be made by opening the chest, 
after due consideration of the mechanics of the vulnerating force. 

Complicating abdominal wounds are common, implying necessarily 
injury to the diaphragm. 

Unless the distinction between a wound which does and one which 
does not involve the lung be fairly obvious, it cannot be made except by 
operation. 

The hemothorax of chest wound may be absorbed very slowly. Often 
it suppurates, the symptoms of acute empyema then developing. 

Hernia of the lung follows as a late sequel of wounding and at times of 
contusion. It is characterized by the appearance of a resonant crepitant 
projecting tumor responding to the influence of intrathoracic tension. 

Wound of the Heart. — Wound of the heart, if not immediately fatal, 
is characterized by profound shock, irregular, feeble, rapid heart action, 
and marked dyspnea. In framing a diagnosis, the probable depth and 
direction of the wound, as suggested by the vulnerating agent and its 
points of entrance and of exit, are of major importance. 

Blood effusion into the pericardial sac and hemothorax are corrobo- 
rative symptoms if they are present. If the wound be of sufficient size 
to allow direct exploration, a positive diagnosis can be framed. Other- 
wise, it must depend upon exploration, which would be called for in any 
event by progressive bleeding. 

A wound of such nature and direction as to probably involve the heart 
should be regarded as such so far as absolute physical quietude of the 
patient is concerned, since there may be neither shock, hemorrhage, 
nor other characteristic symptoms immediately following heart lesion. 
Pericardial blood effusion following a wound immediately or shortly 
(hours) or developing suddenly later (days) is almost pathognomonic 
evidence of heart lesion. 

Fracture of the Sternum. — Fracture of the sternum, usually transverse, 
near the point of junction of the manubrium and body, at times a true 
diastasis, may be caused by direct blow, in which case the injury may 
be comminuted, by muscular action, or by forced flexion or extension. 
If there be displacement, the lower usually over-rides the upper fragment 
and the diagnosis is readily made. In the absence of displacement, 
persistent tenderness and late ecchymoses following an adequate cause 
other than direct violence are significant. This injury is a not infrequent 
complication of vertebral fracture dislocation in the cervicodorsal region. 

Fracture or dislocation of the ensiform process (rare) is characterized 
by obvious displacement, preternatural mobility, and in a few recorded 
cases by recurring attacks of pain and vomiting. 

Fracture of the Ribs. — Fracture of the ribs, from direct or indirect 
force or muscular action, usually involving the fifth or eighth, often a 
number of ribs, attended, as a rule, by little deformity and situated, even 
when due to indirect force, near the point of application of this force, is 
characterized by pain, well localized, and greatly aggravated by coughing 
or deep breathing, tenderness, at times crepitus, and undue mobility. 



INFLAMMATIONS OF THE CHEST 455 

Crepitus with undue mobility may be elicited by direct palpation of each 
rib; at other times by placing the thumb of each hand on the extremities 
of the suspected rib and making alternate or synchronous pressure 
against the side of the chest with the flat of the hand, while the patient 
breathes deeply or coughs. 

The diagnosis must often be based, in the absence of the ic-rays, on 
the persistent pain and the extreme local tenderness to deep palpation. 

Fractures by muscular contraction usually involve the lower ribs^ and 
may occur as the result of movements calling for no undue strain upon 
the bones, such, for instance, as coughing or sneezing, or even turning 
in bed. Such fractures of the ribs have not the same significance as do 
those from inadequate cause affecting the bones of the extremities 
(bone tumor), and may be so wanting in symptoms that the appearance 
of callus may first call attention to their existence. 

Fracture of the ribs may be complicated by wound of the pleura or 
lung, as evidenced by cough, pleuritic friction sounds, emphysema, 
exceptionally pneumothorax. The superficial emphysema is manifested 
as a rapidly spreading swelling which crepitates on palpation and may 
extend over the entire body. 

Hemorrhage from an intercostal artery with bleeding into the pleura 
is a rare complication of fracture of the rib. 

Fracture of the Costal Cartilages. — Fracture of the costal cartilages, 
commonly involving those of the seventh and eighth ribs, is usually 
characterized by pronounced lateral displacement, at times by over- 
riding, and is then easily recognized. Persistent local tenderness and 
pain, especially marked in movements calling the abdominal muscles 
into play are the characteristic symptoms in the absence of displacement. 

Inflammations of the Chest.— The Skin.— The skin of the thorax 
may be the seat of any of the inflammatory or neoplastic lesions to 
which this structure is subject. Acne and seborrheic eruptions are 
especially frequent, and over its lower lateral surface the first manifesta- 
tion of syphilitic roseola is often seen. Boils and carbuncles, less 
common than on the back of the neck, are fairly frequent on the lateral 
chest wall. 

Osteomyelitis. — Acute osteomyelitis of the ribs and sternum (rare) is 
manifested by hyperacute, constitutional symptoms of infection, severe 
pain, local tenderness, and the rapid development of edema and abscess. 
The diagnosis should be confirmed by operation. 

Chronic osteomyelitis, usually tuberculous, syphilitic, or typhoidal, 
at times an evidence of an attenuated or well-resisted pyogenic infec- 
tion, is characterized by the gradual (weeks) development of a moderate 
bone swelling, fusiform if a rib be involved, which is usually neither 
markedly painful nor tender. Softening and sinus formation are fairly 
prompt. The first evidence of such an infection may be a fluctuating 
tumor due to cold abscess extending toward the surface. 

Typhoidal hone infection is superficial and limited in extent. It 
occurs during or after convalescence, exhibits a special predilection for 
the ribs, and is placed on the outer surface of the bone near the osteo- 



456 



THE THORAX 



cartilaginous junction. The diagnosis is based upon the development of 
one or more fusiforra, slightly tender rib swellings after typhoid fever. 



Fig. 331 




Multiple osteoperiostitis ten months after typhoid fever; semifluctuating, non-sensitive painless 
tumors attached to ribs covered by healthy skin. X-ray negative. Rapid (weeks) formation. 



Tuberculous osteomyelitis, which may be either central or peripheral 
in origin, may form a cold abscess which may burrow wide of its original 
seat. The tracing of the resultant sinuses may be difficult in the absence 
of palpable bone tumor. It is facilitated by iodoform injection and 
ir-ray pictures. The tuberculous nature of the infection is determined by 
the tuberculin test and examination of the discharge. 

Such a cold abscess may persist after healing of the bone lesion. 

Gumma. — Gumma of the ribs and sternum, fairly common seats, 
is manifested by an indolent infiltration which increases in size more 
rapidly than that of tuberculosis and exhibits softening at an earlier 
period (weeks). Nor is there the same tendency toward extensive 
sinus formation, the opening usually being direct. The diagnosis is 
based on associated symptoms and signs of syphilis and on the effect of 
appropriate constitutional treatment. 

Inflammation of the mediastinum in its acute form is generally due to 
an extension of cellulitis from the neck. Septic phlebitis of the jugular 
veins, perforation of the esophagus or trachea by foreign bodies or as 
a complication of malignant disease, suppurating bronchial glands or 



INFLAMMATIONS OF THE CHEST 457 

infections of the pleura, lung, pericardium, ribs, or spine are among the 
causes. 

It is characterized by tenderness elicited by tapping the sternum or 
pressing deeply upon it, dyspnea, irregular feeble heart action, and 
symptoms of profound septic intoxication. 

The anterior mediastinum is commonly involved. Abscess, if it 
extends peripherally, appears to the side of the sternum or in the 
epigastric region. 

Posterior mediastinitis is commonly accompanied by signs of irritation 
of the spinal nerve roots. The external pointing of the abscess is in 
the intercostal spaces or at the root of the neck. 

Pericarditis. — Inflammation of the pericardium is accompanied by 
effusion. This may be serous, formative, or purulent. The presence 
of effusion in quantity is indicated by heart hurry, often irregularity and 
intermission of beats, distant sounds and pronounced increase in the 
area of cardiac dulness, readily demonstrable in the absence of pleural 
effusion. The area is usually pear-shaped, with the base downward. 
If the effusion be large there will be distinct bulging in the cardiac region, 
especially marked in children. 

Hydropericardium may occur as one of the features of a general dropsy, 
and is then associated with bilateral pleural effusion. After scarlet 
fever the pericardium may be the only seat of transudate (Musser). 
Pericardial effusion commonly occurs in pneumonia, rheumatism, or 
tuberculosis. It may complicate typhoid fever, scarlet fever, or pyogenic 
infection in any of its forms. 

The a;-rays may be helpful in diagnosis, but should be supplemented, 
in septic cases with local symptoms, by exploratory incision. 

Adherent 'pericardium may follow an acute pericarditis or may develop 
insidiously in the course of tuberculosis. It is characterized by systolic 
retraction of the interspaces most marked at the position of the apex 
beat and synchronous with systolic shock, outward displacement of the 
apex, increased area of impulse, diastolic shock, collapse of the cervical 
veins during diastole, weakening of the pulse during inspiration and 
upward extension of the area of cardiac dulness not modified by full 
inspiration. There are often signs of an associated pleurisy. These 
findings are associated with the subjective symptoms of either dilatation 
or hypertrophy (Musser). 

Pleural Effusions. — Pleural effusions, with the exception of those trans- 
udates due to venous stasis or blood dyscrasia, which are usually bi- 
lateral and accompanied by ascites, are generally secondary to abnormal 
conditions of the organs invested by the pleura or of the inner portion 
of the walls of the thorax. 

A serous pleural effusion is a common accompaniment of subphrenic 
and perinephric abscess, and is a symptom which may divert attention 
from a spinal osteomyelitis. 

The effusion may be serous, fibrinous, or suppurative; may be acute 
in onset and course and characterized by well-marked symptoms, or 
may be chronic from the first. 



458 THE THORAX 

The serous effusion becomes of surgical importance only when it 
markedly interferes with either respiration or circulation, or both. 

Pain, non-productive, harassing cough, hurried breathing, moderate 
fever, dyspnea on slight exertion are the characteristic symptoms, and are 
corroborated by percussion dulness or flatness, absence of breath sounds 
and vocal fremitus, and displacement of the heart. There is always, if 
the effusion be of considerable size, diminished excursion of the chest 
wall, and enlargement of the affected side. Such a condition, developing 
in the absence of acute inflammatory affection of the lungs, chest walls, 
or lower surface of the diaphragm, and not incident to an acute systemic 
infection, is usually tuberculous. 

Empyema may follow wounds of the pleura or lung. It is a common 
sequel of pleuropneumonia, is not infrequent in tuberculosis, and repre- 
sents the usual direction of extension of the perinephric abscess. 

In addition to the symptoms common to the pleuritic exudate those 
of septic absorption are usually pronounced. The nature of the 
infecting organism can be determined by removal and bacteriological 
examination of the purulent contents. 

The purulent empyema of tuberculous origin may be latent. It is 
not infrequently complicated by pneumothorax. 

Chylothorax, due to trauma of the thoracic duct or its obstruction 
by tumor, exhibits the symptoms of a pleural effusion and is recognized 
by the presence of a cream-like fluid withdrawn by puncture. 

Exploratory puncture of the chest is accomplished by means of a 
syringe of adequate capacity with a needle at least four inches long, 
with a short point, and of sufficient caliber to evacuate by suction a 
thick fluid. 

The points of election for puncture are the sixth interspace in the 
axillary line, the eighth interspace in the scapular line, or at such a 
position as the conditions present indicate. The skin is cleansed, 
anesthetized, and cut through by a stab with a sharp pointed tenotome 
to the subcutaneous fat, thus avoiding the danger of carrying skin infec- 
tion to the deeper parts and enabling the surgeon to feel the lessened 
resistance to the needle point encountered when it has entered the 
pleural cavity. The needle, attached to the syringe, is then inserted, 
with the finger pressed against it at a distance from its point equal to 
the probable thickness of the chest wall in order to prevent it from 
going in too far, close to the upper border of the rib into the chest 
cavity. The piston is slowly withdrawn; if no fluid is obtained the 
needle is slowly pushed farther in. If the first puncture is negative, 
others should be made. A small amount of fluid suffices for the objects 
of an exploratory puncture. The opening is closed with collodion 
unless operation is to follow at once. 

Fluid thus aspirated is examined for its cellular contents and the 
particular form of infection present, a portion being saved in a sterile 
vessel for culture and inoculation should this seem needful. Non- 
traumatic, blood-stained effusion is suggestive of malignant dis- 
ease. 



INFLAMMATIONS OF THE CHEST 459 

Abscess of the Lung. — Abscess of the lung usually follows pneumonia, 
and is suggested by a continuance and exacerbation of the symptoms 
of general infection beyond the time for resolution, without demonstrable 
evidences of further extension of the pneumonic process. Marked 
daily variation in temperature and, particularly, recurring attacks of 
chill, fever, and sweat are characteristic. 

If the abscess be near the lung surface, circumscribed percussion 
dulness is the sign of major import, associated with the usual signs of 
consolidation. If, in the course of these symptoms, there be a sudden, 
profuse, purulent expectoration, and the signs of local consolidation are 
succeeded by those of cavity formation, the diagnosis is assured. The 
ic-rays are helpful in establishing the presence of an abscess and in local- 
izing it. 

Suppurating bronchial glands, septic emboli, foreign bodies, extension 
of suppuration from the postperitoneal structures or the thoracic parietes 
are occasional causes of lung abscess. 

Gangrene of the Lung. — Gangrene of the lung, usually a sequel of 
pneumonia, is attended by symptoms similar to those of abscess. The 
constitutional condition is one of profound sepsis. The expectoration is 
extremely foul. 

Bronchiectasis. — Bronchiectasis, often associated with tuberculosis, and 
observed in alcoholics and diabetics, may closely simulate abscess. It 
is slow in onset, and the constitutional symptoms are those of chronic 
sepsis. In addition to cough, often altered in severity by position, there 
is a profuse purulent expectoration which may be almost odorless or 
extremely foul. It may contain blood, sometimes a considerable quantity 
of it. Constitutional symptoms are not in proportion to the amount of 
discharge. 

Localized Tuberculosis. — Localized tuberculosis of the lung may be 
considered as a surgical affection when an inadequately drained cavity 
is formed. The symptoms are those of tuberculous infection, cavity, 
sepsis, and deterioration in health more pronounced than would be 
usually noted as a consequence of a limited process. 

Echinococcus. — An echinococcus cyst, causing the symptoms of me- 
chanical displacement, including shortness of breath, pain, dulness on 
percussion, and absence of respiratory murmur, is rarely diagnosticated 
as such without exploratory puncture. 

Actinomycosis. — Actinomycosis (rare) in its primary form is character- 
ized by the symptoms of chronic pulmonary tuberculosis. Pleural 
effusion may be the first symptom noted. 

In its ultimate development hard infiltration of the chest wall with 
sinus formation may suggest malignant growth. The diagnosis from 
tuberculosis can be made only by the continued absence of tubercle 
bacilli from the sputum and the negative evidence of the tuberculin test. 
It is made occasionally by finding the ray fungus. 

Syphilis of the Lung. — Syphilis of the lung, developing in its tertiary 
stage as a diffuse or circumscribed infiltration, exhibits the symptoms 
and local findings of pulmonary tuberculosis, nor can a differential diag- 



460 



THE THORAX 



nosis be made except by the persistent absence of the tubercle bacillus, 
the presence of other lesions or signs of syphilis, a history of spirochetal 
infection, and the result of efficient constitutional treatment. 

Tumors of the Thorax. — Lymphangiomata and hemangiomata, sub- 
ject to rapid enlargement, moles exhibiting malignant degeneration, 
and keloid, are congenital tumors common in the skin of the chest. 
Lipoma and jSbroma are frequently seen here, the former simulating 
at times cold abscess, but exhibiting typical lobulations and freedom 
from deep attachment, except when it is of subpleural origin, the latter 
of slow growth and dense consistency, indistinguishable in its beginning 
from sarcoma. 

Fig, 332 




Subcutaneous lipoma of back. Sharply circumscribed tumor movable beneath skin and on 
underlying tissues. Uniform soft consistency simulating fluctuation. Skin dimples on being 
made tense. (Carnett.) 

Subpleural lipoma may project, forming an external tumor, soft and 
lobulated, lying below the muscles and apparently adherent to the chest 
wall. The major part of it may be intrathoracic. Mediastinal lipoma 
may act precisely the same way. These tumors at times grow rapidly. 

Sarcoma of the soft parts, rare, except in the region of the shoulder 
as an extension from the breast or as a malignant degeneration of a 
congenital skin lesion, is characterized by the rapid growth of an appar- 
ently causeless tumor. It should be diagnosticated by complete removal 
and microscopic examination. 

Carcinoma of the chest wall is usually an extension from the breast, 



TUMORS OF THE THORAX 461 

occasionally in the form of a rapid (weeks, months), widely spreading, 
nodular infiltration (cancer en cuirasse) involving a large surface. 

Epithelioma forms a chronic slowly growing ulcer which must be 
diagnosticated by excision. 

Fig. 333 




Hernia through linea alba. Sudden onset during heavy lifting; twenty years' duration; expansile 
impiilse on coughing; incomplete reduction on lying down or by nianipulation ; small, irreducible 
nodule, probably omentum; ring admits tip of thumb. (Carnett.) 

Tumor of the Ribs and Sternum. — The bone tumors of the thorax are 
usually sarcomata. 

Osteoma and chondroma, growing from the region of the costochondral 
junction of the ribs and from that of the manubrium and body of the 
sternum, exhibit, if palpable, characteristic hardness, and in the case 
of osteoma, slow growth. The diagnosis should be made by the i^-rays 
or by exploration. 

Sarcoma, not infrequently post-traumatic, is characterized by its 
rapid growth and by the a:-ray findings. Pressure pain may be severe. 
The distinction from a chronic osteomyelitis may, in the early stages 
of the affection, be impossible; later, the large size without sinus 



462 THE THORAX 

formation or tendency thereto is characteristic. The inward growth is 
commonly much greater than would be suggested by external examina- 
tion. The diagnosis should be made by early complete removal of 
a bone tumor which is not obviously benign. 

Tumor of the Mediastinum. — Exceptionally benign (fibroma, lipoma) 
mediastinal tumor is usually of lymphatic origin, malignant and second- 
ary to cancer of the breast, thyroid, lung, pleura, or esophagus. 

Pressure symptoms, bulging of the chest wall, the development of a 
palpable tumor are the characteristic features of all mediastinal tumors, 
malignancy being suggested by rapid progression. 

The pressure symptoms are radiating pain, both deep and localized; 
harassing, futile cough; dyspnea, often with stridor; pleural effusion; 
venous congestion of the head, chest, and upper extremities, with 
occasionally chest edema; hoarseness or loss of voice; displacement of 
the heart, displacement of the trachea, difficulty in swallowing, and 
rapid emaciation. 

Percussion dulness will be elicited if the tumor lie near the sternum. 
Palpation deep in the suprasternal notch may enable the tumor to be 
felt. Lymphatic involvement of the lower cervical group of glands is a 
corroborative symptom. These tumors may pulsate and may closely 
simulate aneurysm. The ir-rays may be helpful. 

Tumor of the Pleura. — Tumor of the pleura, usually secondary 
endothelioma, if primary, is characterized by a pleuritic exudate and 
a profound deterioration in general health. It is usually regarded as 
tuberculous until aspiration reveals a blood-stained fluid. Positive 
diagnosis is made by direct exploration through an incision. 

Tumor of the lung, rare except in its secondary form, is characterized 
by the symptoms of circumscribed consolidation without mucopurulent 
expectoration. There is commonly an associated pleural exudate, a 
profound cachexia, and later there may be bloody expectoration. The 
a:-rays may be helpful in diagnosis. 

Aneurysm of the Aorta. — Aneurysm of the aorta, usually from the 
ascending portion of the arch, if it produce symptoms, is characterized 
by those of pressure, such as are common to mediastinal tumor, but with 
dyspnea and difficulty in swallowing more marked, and not infrequently 
by tracheal tug. When the growth reaches sufficient size to form a 
palpable external tumor, the thrill and expansile pulse are usually 
characteristic. These symptoms may be absent. 

The occasional difficulties of diagnosis are exemplified by the circum- 
stance that such aneurysms have been opened because of the diagnosis 
of cold abscess. 

The x-vsijs are often diagnostic. Aspiration should be employed in 
case of doubt. 

THE BREAST. 

In the superficial layer of fatty tissue overlying the muscles of the 
anterior chest wall is the mammary gland made up of from fourteen 



THE BREAST 463 

to twenty lobes, each provided with a duct opening on the surface of 
the nipple, exhibiting a narrowing near its orifice, and a dilatation be- 
neath the areola. These lobes are bound together by a fibrous invest- 
ment which sends numerous extensions to the skin and which intimately 
connects the latter with the deep fascia at the lower margin of the gland. 

Surrounding the breast there is an abundant fatty investment which 
penetrates between the lobes and which mainly gives the gland its full, 
rounded shape. The breast is loosely attached to the pectoral fascia, 
and, though in the main disk-shaped, exhibits aberrant extensions. 
The one toward the axilla is fairly constant and may be so widely 
separated from the rest of the gland as to suggest a distinct tumor. 

Two peripheral extensions are usually found along the inner margin 
of the breast and the gland structure at times dips into the substance 
of the pectoral muscle. 

The small nodules in the thin, pigmented skin of the areola which 
develop at puberty are sebaceous glands. 

The arterial supply is from the internal mammary through perforating 
branches, from the axillary through the long thoracic and acromio- 
thoracic, and from the intercostals. 

The venous return is through the axillary and internal mammary 
vessels. 

The superficial lymphatic vessels pass from the overlying skin of the 
breast, with the exception of that covering the nipple and areola, into the 
thoracic group of axillary glands; these vessels communicate freely with 
those of the other breast. The lymphatics of the nipple, areola, and 
glandular tissue pass to the upper inner group of the axillary glands, 
through the substance of the pectoralis major muscle to the retropectoral 
glands, and to the group lying below and above the clavicle and through 
the intercostal spaces to the retrosternal glands. x\ll the axillary gland 
groups intercommunicate. 

The breast remains rudimentary in both sexes until the age of puberty, 
when in the woman it attains its physiological development. It then 
forms a soft, semiglobular, movable mass, which, with its outlying nodules, 
can usually be distinguished from the investing fat by gentle palpation, 
giving to the examining hand a sense of density greater than that of the 
surrounding fat and of fine, soft lobulation. 

Palpation of the mammary gland is best effected by placing the patient 
in the dorsal decubitus, with the hand of the side to be examined carried 
to the back of the neck. The skin should be freely movable over the 
gland at all points except at the areola and the submammary fold. 
Nodules or indurations are detected both by grasping the substance of 
the gland transversely and vertically between the forefingers of the two 
hands, by palpating portions of it between the finger and thumb of 
one hand, and finally by a pressing rolling motion of the fingers com- 
pressing the gland against the pectoral and serratus muscles. 

Examination of the axilla for enlarged glands is facilitated by the patient 
placing her hand on the umbilicus. The examining finger should be 
carried to the deepest part of the arm pit, and should take in not only 



464 THE THORAX 

its thoracic aspect but the inner and lower surfaces of its anterior wall. 
Moreover, the supraclavicular and infraclavicular regions should be 
carefully palpated. 

General Symptomatology. — ^The most conspicuous and significant 
symptom of affections of the breast is swelling. This may be diffuse 
or localized, and may or may not be accompanied by symptoms of acute 
inflammation. 

The affections which are characterized mainly by increased size of 
the entire breast, with inflammatory phenomena slight or wanting, are 
hypertrophy; the rapid gland growth incident to puberty, pregnancy, 
and lactation; mastitis of the newly born; the congestive enlargement 
in women at beginning of sexual life; and, exceptionally, infiltrating 
carcinoma. 

Affections mainly characterized by acute or subacute inflammatory 
phenomena are furuncle, supramammary and submammary abscess, 
suppurative mastitis, and diffuse carcinomatosis. 

Ulcerating lesions which begin superficially are fissure or erosion, 
chancre, mucous patch, eczema, Paget's disease, and epithelioma. 

Affections which begin as circumscribed tumors with inflammatory 
symptoms slight or absent are neoplasms, solid or cystic, benign or 
inalignant, tuberculoma, cold abscess (rare), and actinomycosis (rare). 

The tuberculoma and gumma soften and ulcerate through the skin 
before they reach the size of a fist (two to six months); ulceration of 
malignant tumors does not occur until they reach much larger size. 

The axillary glands are enlarged rapidly (days) in consequence of the 
congestion and hyperdevelopment of pregnancy, in all forms of acute 
infection of the nipple, breast, and surrounding fat, and in chancre. 
They enlarge slowly (weeks or months) in tuberculosis, cold abscess, and 
carcinoma, exhibiting in the former case a tendency to soften when they 
have reached the size of the thumb, often becoming converted into sacks 
of pus. The cancerous lymphatic enlargement is hard, and in the early 
stages multiple and discrete. 

Discharge from the nipple other than milk occurs as an expression 
of vicarious menstruation, of acute and chronic mastitis, and of both 
benign and malignant growths. A blood-stained discharge is in itself 
not indicative of malignancy. 

Malformations. — ^The breast may be absent (amastia) or aberrant 
and supernumerary (polymastia). It may be atrophied entirely or in part 
or hyper trophied. The nipple may be absent (athelia) or aberrant and 
supernumerary (polythelia). It may be extremely short, or retracted 
and umbilicated. 

Congenital Malformations. — ^Amastia and athelia, or absence of breast 
and nipple, may be unilateral or bilateral. This deformity is extremely 
rare, and has been noted in association with congenital defects of the 
thorax and absence of the ovary of the affected side. 

Polymastia and polythelia, or supernumerary breast and nipple, are 
fairly common deformities, toward the development of which heredity 
is a distinct predisposing factor. The misplaced glands are usually 



THE BREAST 465 

small and functionless and are found in the anterolateral thoracic regions, 
though they have been noted on the face, thigh, external genitals, shoulder, 
and in a number of instances in the axilla. The anomaly is commonest 
in males. Lichtenstern found 3 out of 72 multimammiferous women 
who bore twins. 

The short or umbilicated nipple due to malformation or the extreme 
invagination noted at times in the fatty, pendulous breast, must be 
distinguished from retraction which is a characteristic sign of carci- 
noma and which develops in the course of months in a nipple of pre- 
vious proper conformation. 

The diagnosis of supernumerary breasts and nipples is either obvious 
or possible only by excision and microscopic examination. A super- 
numerary breast without a nipple resembles closely a fatty tumor, and 
supernumerary nipples without underlying breasts may simulate pig- 
mented warts and nevi. 

Atrophy of the Breast. — Atrophy of the breast, rarely complete, attributed 
to the mastitis occurring shortly after birth, may be unilateral or bilateral, 
and is often associated with genital infantilism. The overlying fatty 
tissue may conceal the deformity. 

There is no enlargement at puberty or milk secretion after gestation. 

Hypertrophy of the Breast. — Hypertrophy of the breast affects both 
sexes and is characterized by a rapid and abnormal growth of the entire 
gland. It exhibits a predilection for young girls after puberty and for 
women in the early months of pregnancy, appearing as a rapid, painless 
enlargement of one or both breasts so symmetrical as to cause a feeling 
of satisfaction, which in the course of days or weeks is changed to one 
of alarm as the growth becomes a deformity. It progresses rapidly, 
reaches enormous dimensions, is attended by systemic depression, and 
is uninfluenced by medical treatment. That form which develops during 
the early part of gestation usually disappears after delivery, though the 
child is likely to be puny. 

The diagnosis of hypertrophy of the breast is based upon the rapid 
symmetrical progressive increase in the size of the entire gland without 
inflammatory phenomena, localized induration or skin adhesion. 

Hypertrophy of the male breast (gynecomastia) is usually bilateral 
and moderate in development, forming a globular projecting mass such 
as is normal to a young, unmarried woman, readily distinguishable upon 
palpation from the fat of this region. 

Though often associated with genital defects, it occurs in healthy, 
sexually developed, potent men, the breast reaching its abnormal size 
at or shortly after puberty. It may follow the destruction or removal 
of the testes between the twentieth and the twenty-fifth year of life. 
Neither the completely grown adult nor the infant exhibits gyneco- 
mastia as a result of castration. 

Nipple and Areola. — Dilatation of the galactophorous ducts may 
sometimes be seen as a soft, club-shaped swelling, lying just beneath 
the skin. Papilloma of the duct characterized by a bloody discharge 
has been felt as a slightly movable nodule. 
30 



466 THE THORAX 

Furuncle. — Furuncle of the areola, commonest in nursing women, 
develops in the sebaceous glands, forming one or more small, superficial, 
painful, tender, inflamed, hard nodules which shortly soften and dis- 
charge. By confluence they may form short sinuses beneath the skin. 

Fissures of the Nipple.- — Fissures of the nipple, predisposed to by 
vices of conformation and uncleanliness, are caused by repeated trau- 
matism and infection, hence are common in women who are nursing 
babies with sore mouths. They are often multiple and may be deeply 
destructive. 

Chancre of the Nipple and Areola. — This is often bilateral and multiple, 
and may exactly simulate fissure. Axillary adenopathy, more indolent 
and hyperplastic in type than that characteristic of simple fissure, 
associated with an indurated ulcerating lesion which does not respond 
to local treatment, should excite a suspicion of syphilis. The diagnosis 
is made by finding the Treponema pallidum. 

Eczema. — Eczema forms a red, raw, irregular, crusted patch of excori- 
ated skin about the nipple, which yields to the treatment appropriate 
to this condition when it appears elsewhere. 

Fig. 334 



f A 


■^ 


^ 

/ 


\ 1 


HS^n^ 




H a 


H^^Hk 


i 


-i. 


^^Hp 




^. 


J 






^ 





Paget's disease of the nipple; long duration; followed by carcinoma of the breast, (Hartzell.) 

Paget's Disease. — Paget's disease closely resembles eczema, but differs 
from it in being rebellious to treatment. It is followed by carcinoma. 
The diagnosis is based on persistence and slow extension in spite of 
careful treatment, and finally on excision and microscopic examination. 

Epithelioma of the Nipple and Areola. — This is characterized by the 
slow formation (months) in women past middle age of an indurated, 
jagged, destructive ulceration accompanied by enlargement of the axillary 
glands. The diagnosis should be made by immediate excision. 

Supramammary and Submammary Abscess. — Acute supramam- 
mary abscess develops commonly in the fatty tissue lying about the 
lower segment of the gland, especially in those whose breasts are large 
and pendulous. The symptoms are acute and obvious, the rapid skin 
involvement showing the superficial nature of the infection. 



THE BREAST 467 

Acute submammary abscesses are always secondary to suppurative 
mastitis, systemic infection, or traumatism. The loose, cellular tissue 
at this point favors the rapid accumulation of pus which thrusts the 
whole breast forward. 

The diagnosis is based upon the presence of an adequate cause 
(mastitis), the forward projection of the entire breast, the finding of an 
edematous collar about it, glandular involvement, and the constitutional 
and blood symptoms of infection. 

Chronic submammary abscess, usually secondary to caries of the ribs 
or sternum, or extension of pus from the mediastinum, forms a deeply 
placed tumor not movable on the chest wall. This fact should suggest 
the diagnosis, though it is not usually determined until operation. 

Mastitis. — Swelling of the breast, with slight heat and tenderness, 
and at times an associated transitory adenopathy, is observed shortly 
after birth, at puberty in both sexes, and in the female at the beginning 
of sexual life and during pregnancy and lactation. 

The mastitis of infancy develops in both sexes a few days after birth, 
is transitory, and is attended by a milky discharge from the nipple. 
Exceptionally abscesses form, or the inflammation, becoming chronic, 
may cause atrophy. 

The mastitis of puberty (both sexes) may be attended by a serous dis- 
charge from the nipple. It subsides within a week. Exceptionally 
abscess forms; this is likely to be superficial and single. 

With the assumption of sexual life the breasts of women swell and 
become tender, often vaguely nodular. This is a transitory condition 
not leading to infection. 

Lactation mastitis is commonest in primipara who nurse their 
children, and develops, as a rule, in the first months after childbirth. 

The essential predisposing conditions are overdistention of the breast 
with its normal secretion, exposure to cold, and infection, often from a 
fissured nipple. 

Lactation mastitis may appear in the form of a tender induration 
which may subside promptly, may quickly develop the symptoms of 
acute suppuration, or may persist and slowly enlarge and soften, forming 
a chronic abscess. 

If the primary induration does not subside, it usually becomes acutely 
painful, the overlying skin is edematous, the constitutional and blood 
symptoms of infection are present, and fluctuation soon develops. 

Chronic mastitis is characterized by persistent induration which may 
form an indolent abscess or may undergo mahgnant degeneration. 

The diagnosis as to the nature of a persistent infiltration or a fluctu- 
ating tumor of the breast developing during lactation should be made 
by exploratory operation. 

Acute puerperal mastitis may be total (rare). This form of infection 
is characterized by sudden, violent, overwhelming inflammation of the 
entire breast. The constitutional symptoms are those of profound 
toxemia. It may terminate in gangrene characterized by dusky dis- 
coloration of the skin, vesication, and extrusion of large sloughs. 



468 THE THORAX 

Tuberculous Mastitis. — Tuberculous mastitis in about half the reported 
cases has developed in young women without other tuberculous lesions. 
It is at times secondary to tuberculous axillary lymphadenitis. It is char- 
acterized by a slowly growing, vaguely outlined, painless, at first non- 
inflammatory, dense induration, usually in the central zone of the breast. 
In about three months this tumor, having reached the size of a child's 
fist, fluctuates and ulcerates through the skin which is undermined, 
but not infiltrated and adherent. The axillary glands are enlarged early 
(one month) and are more inflammatory in type than is the involvement 
of carcinoma. They may soften and discharge cheesy pus while the 
breast tumor is still forming. 

Mammary tuberculosis might be suggested by the presence of tubercu- 
losis elsewhere, and particularly of obviously tuberculous glands in the 
axilla. It begins precisely as does cancer. Hence its true nature should 
be determined by immediate excision and examination. 

Syphilitic Mastitis (rare). — Gumma of the Breast. — This is often bi- 
lateral, forms a hard, painless, rounded tumor, unattended by either 
adenopathy or systemic symptoms. In one to three months, and before 
it has reached a size greater than that of an egg, it softens and ulcerates, 
forming a typical, punched-out, non-proliferating ulcer. Axillary 
adenopathy may now develop from mixed infection. 

In its early stages this infiltration exactly simulates malignant growth. 
The differential diagnosis must be by excision and microscopic examina- 
tion, though a clear history of syphilis with associated manifestations of 
this disease might suggest the therapeutic test of mercury and the iodides. 

Hydatid Cyst. — Hydatid cyst (very rare) forms a round, hard tumor, 
which in the course of two years is prone to inflammation and suppu- 
ration. The diagnosis can be made only by excision. 

Sebaceous Cyst. — Sebaceous cyst develops in the skin, forming a 
globular, finally disk-shaped, moderately hard tumor, superficially placed, 
slow in growth (years), and discharging from its central aperture on 
firm pressure or through a puncture the characteristic semisolid, cheesy 
substance. It has been mistaken for carcinoma. 

Galactocele. — Galactocele developing in the lactating breast is char- 
acterized by the rapid formation of a cyst without inflammatory 
phenomena. Pressure upon the cyst may cause milk to flow from 
the nipple. The condition may become chronic, the contents of the 
cyst then becoming thick and oily. 

Tumors. — Since tumor of the breast is usually painless, its presence 
is often not suspected by a patient until it is sufficiently large to be 
accidentally felt or seen. This implies a growth of weeks or months, in 
which time it may have developed the characteristics of assured benig- 
nancy or of assured malignancy. 

A great number of tumors when they first come under observation 
cannot be classified under either of these headings. If gumma be 
excluded, the diagnosis in these doubtful cases should be formulated 
immediately by removal of the tumor and the glandular tissue sur- 
rounding it, and macroscopic and microscopic examination. 



THE BREAST 



469 



Among the assuredly benign growths may be classed tumors which 
develop in the breasts of girls and young women, and which are rounded, 
firm, elastic, sharply circumscribed, movable, and unaccompanied by 
atrophy of the overlying fat, skin adhesion, or glandular enlargement. 
Such tumors (intercanalicular myxoma, adenofibroma, solid or cystic) 
may be single or multiple, but are usually small and slow of growth. 



Fig. 335 




Ulcerated cancer of breast; eighteen months' duration; cutaneous pitting resembling orange skin 
(pig skin); retracted nipple at lower third of ulcer. (Carnett.) 



Of similar benignancy are the tumors which develop in women who 
have never borne children, at or about the menopause, and which are 
multiple, cystic, sharply outlined from the surrounding tissues, unaccom- 
panied by atrophy of the overlying fat or skin adhesions, or more than 
a moderate enlargement of the axillary glands. 

Finally, tumors which conform in type with those just described, and 
which have existed for a long time (years) without change in size are 
essentially benign. 

Tumors which are certainly malignant are characterized by the develop- 
ment of a single, hard, infiltrating mass of irregular outline and vague 
definition, associated with atrophy of the overlying fat, skin dimpling, 
and retraction of the nipple. This last symptom, when but slightly 
marked, must be demonstrated by comparing its freedom of motion when 
drawn forward with that of the nipple of the healthy breast. 

Skin dimpling and fat atrophy are elicited by broadly encircling the 



470 THE THORAX 

breast tissue about the growth with the two hands, Hfting this segment 
away from the chest wall, and pressing the hands together. Multiple, 
indurated, non-sensitive axillary glands, if present, afford further cor- 
roboration of the malignant nature of the induration. All forms of 
cancer in the late, usually inoperable, stage offer the clinical picture of 
assured malignancy. 

Whether the tumor be single or multiple, solid or cystic, rounded or 
lobulated, if it exhibit rapid growth after a quiescent period, or if it be 
not clearly and definitely outlined from the surrounding breast tissue, 
the diagnosis should be formulated by operation. 

The operative diagnosis of benignancy is based mainly upon the 
presence of distinct encapsulation ; in the case of cysts upon the presence 
of clear or opalescent fluid, unless there be an associated intracystic 
papilloma, when the cyst contents may be blood-stained; and upon 
the thin white walls and distinct demarcation from the surrounding 
tissues. 

The operative diagnosis of malignancy is based upon the absence of 
distinct and complete encapsulation, infiltration into the surrounding 
breast tissue, creaking under the knife and brittleness of tissue, and on 
the presence of granular debris in fibrous spaces. 

In the case of cysts, the bloody or grumous contents, fungating intra- 
cystic growths, thickening and irregularity of the cyst wall, and particu- 
larly infiltration of the tissue surrounding the base of the fungating 
intracystic growth, are evidences of malignancy. In case of doubt after 
careful consideration of the clinical history and macroscopic examination 
of the excised growth a complete breast operation should be performed. 

Mastodynia. — This is characterized by pain so severe and recurrent 
or persistent as to be crippling. It is most marked about the menstrual 
period. It may radiate widely, and may be associated with distinct 
induration, either local or disseminated, over the whole breast, giving to 
the examining fingers the sensation of a finely lobulated connective-tissue 
mass. Exceptionally the breast is entirely normal to palpation, though 
it may exhibit points of tenderness. The overlying skin is at times 
hyperesthetic. 

The diagnosis is often entirely symptomatic. If careful palpation 
reveals one or more small, superficial, excessively tender nodules, neuro- 
fibromata would be suggested. Marked induration of the whole breast, 
giving to the examining fingers the sensation of a bag of fine and large 
shot, is indicative of chronic mastitis. Paroxysms of pain characterized 
by sudden swelling, with complete and rapid subsidence, especially if 
associated with other nervous phenomena, are, for lack of a better desig- 
nation, termed hysterical. 

The affection is persistent, exhausting, and unlikely to yield to treat- 
ment. In the presence of demonstrable lesions, therapeutic indications 
are plain. 

Spontaneous ecchymosis of the breast has been noted, often preceded 
by severe pain and some swelling of the breast, accompanied by or 
without other symptoms. It is always associated with menstruation. 



THE ESOPHAGUS 471 



THE ESOPHAGUS. 



The esophagus, beginning at about the upper border of the cricoid 
cartilage, on a level with the sixth intervertebral disk, ends a little short 
of an inch below the diaphragm, opposite the body of the eleventh dorsal 
vertebra. 

Its beginning in the adult is five and a half to six inches from the line 
of the teeth, its termination at the cardia is from fifteen to sixteen inches 
from the same line, this last measurement being less or greater by two 
inches, in proportion to stature. The distance from the teeth to the 
cardia of children from two to twelve years old is from nine to eleven 
inches. 

There are three points of narrowing — the beginning, the position of 
the crossing of the left bronchus, and the site of passage through the 
diaphragm. 

In the adult the esophagus should admit from above an instrument 
15 mm. in diameter; from the stomach aspect, three fingers as far as the 
first joint. 

Its upper end cannot be reached by a finger introduced through the 
mouth, nor is it accessible to palpation, excepting in its cervical portion, 
where it bends slightly to the left. 

It is explored by means of soft rubber tubes, flexible woven bougies 
(cylindrical, conical, rat-tailed, and elbowed), bougies made with a 
flexible handle twenty inches long, to which can be attached metal bulbs 
of varying diameter, or the esophagoscope. 

Instrumental examination should be preceded by thrice painting the 
pharynx and base of the tongue at three minute intervals with 20 per cent, 
eucaine lactate and 0.01 per cent, adrenalin chloride solution. In weak 
patients death from cardiac inhibition has resulted from the attempt 
to pass esophageal instruments. 

Soft, flexible instruments are passed with the patient in a sitting posi- 
tion, his head leaning slightly forward. The surgeon's left index finger 
is passed to the base of the tongue and guides the tip of the instrument 
backward against the posterior wall of the pharynx while it also holds 
the tongue forward. Muscular spasm, violent cough, dyspnea, and 
vomiting efforts usually make the first essay difficult. Once having 
entered the esophagus, the head of the patient may be extended. The 
further passage of the instrument into the stomach is, in the no;*mal 
esophagus, unobstructed. 

Direct inspection is practicable through the esophagoscope, a long 
straight tube of from 10 to 15 mm. diameter and varying in length in 
accordance with the needs of the case, provided with a cold lamp in its 
extremity and a conical obturator. Its introduction is possible only with 
the head in a position of extreme extension. It forces the cricoid carti- 
lage forward and produces bruising of the upper extremity of the esopha- 
gus. It gives a view of the esophageal walls throughout their entire 
extent. 



472 THE THORAX 

Auscultation of the esophagus to the left of the spine of the eleventh 
dorsal vertebra is useful at times. Fluid is by a swallowing motion 
squirted into the lower part of the esophagus, where it remains six seconds. 
The cardiac orifice of the stomach then opens and the fluid enters this 
viscus with a gurgling sound. Delay of this sound or its absence would 
suggest narrowing or spasm at or near the cardia. 

The cardinal symptoms of esophageal disease are difficulty in swallow- 
ing, pain usually aggravated by this act, regurgitation of food which 
does not contain gastric juice, and often reflex cough. 

These symptoms are also characteristic of inflammations of the pharynx 
and tonsils, postpharyngeal abscess, and palsy of the palate or of the 
pharyngeal constrictors. 

The throat lesions' which cause these symptoms are amenable to direct 
inspection and palpation, in cases of inflammation and abscess, and the 
pain is referred to the throat. 

The regurgitation incident to palsy secondary to infectious disease, 
particularly diphtheria, is immediate and usually partly nasal. 

Congenital Malformations of the Esophagus. — ^This portion of the ali- 
mentary canal may be transposed, duplicated, dilated, or strictured. It 
may be imperforate or may exhibit fistulse. 

Congenital stricture, characterized by lifelong difficulty of deglutition, 
is often associated with diverticula. 

Esophagotracheal fistula causes a spasmodic coughing up of the 
ingested fluid when the infant is nourished. 

Imperforate esophagus may take the form of diaphragmatic closure 
or complete absence. 

Rupture of the Esophagus. — Rupture of the esophagus occurring during 
violent vomiting has been noted in the lower end of this tube, probably 
predisposed to by abnormal condition; characterized by violent pain, 
shock, inability either to swallow or vomit, emphysema at the base of 
the neck, and death within twenty-four hours. 

Diagnosis might be suggested by the dysphagia and the prominence 
of the thoracic symptoms. 

Acute Esophagitis. — Acute esophagitis, usually due to the ingestion of 
a corrosive liquid, is usually masked in its symptomatology by the asso- 
ciated lesions of the mouth and stomach which establish the diagnosis. 
The tissue necrosis is greatest at the three points of normal narrowing. 

The esophagus may be traumatized from within by instrumentation 
or by the swallowing of small sharp or pointed foreign bodies which 
may or may not be arrested in its substance. Instrumentation may cause 
perforation and abscess, but not in a healthy esophagus. It often occa- 
sions an acute catarrhal esophagitis limited to the upper orifice. 

The acute inflammation incident to the lodgement of a small sharp 
foreign body is characterized by sudden sticking pain fairly well localized 
behind the sternum, aggravated greatly by swallowing solids, growing 
worse shortly (hours or days), followed by dysphagia, the constitutional 
symptoms of infection, and often the eructation of blood and pus. 

This condition is distinguished from the burning pain incident to an 



THE ESOPHAGUS 473 

esophageal scratch, from the circumstance that the latter within twenty- 
four hours begins to grow better, and the slight dysphagia is one of pain 
rather than of mechanical obstruction and muscular infiltration. 

Acute inflammation secondary to periesophageal phlegmon of verte- 
bral, glandular, or tracheal origin would probably be suggested by the 
symptoms of the primary disease and the absence of other adequate 
cause. There is burning pain aggravated by swallowing, or at times 
even by moving the neck, and usually the constitutional signs of 
profound toxemia. 

Foreign Bodies. — Foreign bodies, particularly frequent in children, are 
arrested at either extremity of the esophagus or the position of the bron- 
chial crossing. The characteristic symptoms are great and suffocating 
pain, fruitless vomiting efforts, strangling cough, and dysphagia. Fatal 
dyspnea may result from the high lodgement of a large body. In hours 
or days (exceptionally weeks) the constitutional and local symptoms of 
infection develop. Periesophageal suppuration may lead to mediastinal 
infection and inflammation of the pleura and pericardium, or perforation 
into the air passages or the great bloodvessels. 

Though the immediate symptoms, because of the associated laryngeal 
spasm, are, exceptionally, much like those of foreign body in the air pas- 
sages, the dyspnea and cough are usually moderate and the patient by 
his own sensations makes the correct diagnosis. This should be made 
absolutely and immediately by the :r-ray when this is applicable (teeth, 
coins, etc.), the esophageal bougie, and, in the case of small sharp bodies 
(fish-bones), by the esophagoscope. 

Esophagismus. — Esophagismus, manifested by involuntary contrac- 
tion of the upper opening of the canal, is a neurosis usually occurring 
in young women exhibiting other signs of hysteria. It is an occasional 
reflex of an erupting wisdom tooth. The attack which comes on sud- 
denly is characterized by dysphagia, eructation of the pharyngeal con- 
tents, pain, often severe, a sense of constriction, and dyspnea. These 
symptoms may recur at each effort at deglutition for days or months. 
More commonly they are distinctly intermittent, and the difficulty in 
swallowing corresponds to no mechanical law, since warm food can 
sometimes be taken with ease while cold food brings on the spasm, or 
one liquid may be taken with impunity while another equally bland is 
promptly rejected. 

The diagnosis is suggested by the immediate rejection of food before 
it leaves the pharynx, the high seat of pain, the variability of the symp- 
toms, and is confirmed by an examination with a bulbous bougie under 
an anesthetic. 

Cardiospasm. — Cardiospasm may be acute in onset, especially when 
it follows traumatism to the chest wall. It may be reflex or incident 
to degenerative changes in the vagus. This nerve sends fibers to the 
intrinsic ganglia of the cardia which keep this muscle in a condition of 
tonic contraction; this contraction will be permanent if the inhibitory 
fibers are destroyed. 

Cardiospasm is characterized in its beginning by much the same 



474 THE THORAX 

symptoms as esophagismus, except that the burning pain and point of 
stoppage are located behind the midportion of the sternum. In the 
early stages food is regurgitated at once. 

The symptoms may be evanescent, recurring, or persistent. 

The bougie is resisted strongly just as it is about to pass into the 
stomach (sixteen inches from the line of the teeth), but on sustained 
gentle pressure passes in quite suddenly. Moreover, a large instrument 
will at times pass more readily than a small one. 

Cardiospasm with Diffuse Dilatation of the Esophagus. — ^This is char- 
acterized by precisely the symptoms of deep diverticulum. There 
is increasing dysphagia, pain behind the sternum after eating, dry 
cough, and eructation of putrid food. On lying down, there is an almost 
effortless regurgitation of food unmixed with gastric contents. This 
regurgitation occurs at other times often assisted by voluntary muscular 
actions having for their end increased intrathoracic pressure. There 
is no vomiting or belching of gas. 

These patients select their diet most carefully, and often go through 
extraordinary movements to force the food into the stomach. With 
the fusiform dilatation of the esophagus there is usually an associated 
muscular hypertrophy of its walls. 

The diagnosis is based upon the deep position of the obstruction, 
42 cm. from the line of the teeth, its yielding to steady gentle pressure, 
its irregularity, since at one time an instrument passes readily, while at 
another its introduction is impossible. Examination with the esophago- 
scope shows a lax, catarrhal, dilated esophagus, obstructed at the cardia 
by muscular spasm. 

The prognosis of the affection in its progressive form (increasing 
dilatation) is bad. It may last through a long life unrecognized if 
the dilatation is adequately combated by hypertrophy. 

The round peptic ulcer attacks the esophagus directly or in the form , 
of an extension from the stomach. It may bleed freely, thus simulating 
gastric ulcer. 

Both tuberculous and syphilitic lesions have been observed, but give 
no characteristic symptoms other than those incident to subsequent 
cicatricial contraction. Papillomata and retention cysts have been 
seen through the esophagoscope. 

Varices of the lower part , of the esophagus (in atrophic cirrhosis of 
the liver) may cause profuse bleeding indistinguishable from that coming 
from the stomach. 

Stricture of the Esophagus. — Stricture of the esophagus may develop 
within ten days following a chemical destruction of tissue. Usually 
it occurs within six months. When caused by the ingestion of cauter- 
izing agents, it is placed by preference at the points of physiological 
narrowing. There is usually a proximal hypertrophy of muscles, pre- 
venting dilatation, and always a chronic catarrhal condition of the 
mucous membrane, which in itself increases the narrowing. The 
stricture due to either the peptic ulcer, at the lower end of the tube. 



THE ESOPHAGUS '475 

or the gumma, is not preceded by symptoms sufficiently characteristic 
for the formation of a diagnosis of the exciting cause. 

The characteristic symptom of stricture is dysphagia which may 
develop quite suddenly. As a rule, it comes on gradually, first being 
exhibited toward solids, later toward soft food and liquids. Patients 
thus afflicted learn to select their diet with great care, make violent 
efforts at swallowing, and regurgitate masticated food without admix- 
ture of the stomach contents. There is severe poststernal pain, relieved 
by regurgitation. When untreated, the tendency to complete obstruc- 
tion is pronounced. 

Diagnosis is suggested by the history of a preceding esophagitis 
and is assured by examination with bougies. The bougie will exclude 
paralytic dysphagia and esophagismus, and usually cardiospasm and 
diverticulum. 

Stricture due to malignant infiltration is an affection of the middle 
aged, being commonest in men past fifty. It is exceptional before the 
fortieth year. The seats of preference are those of stricture, the greater 
number, perhaps, being found at the bronchial crossing. Chronic 
esophagitis is a predisposing factor. 

The diagnosis is suggested by pain, worse at night and poststernal 
or referred to the back, toxic anemia and dysphagia, not necessarily 
very pronounced, occurring in a man past middle age. Nodular enlarge- 
ment of one or more supraclavicular glands would be corroborative. 

The passage of bougies and the esophagoscope often makes the diag- 
nosis absolute. 

In its early stages the condition is almost never recognized. In its 
later stages regurgitation of masticated food containing blood and 
mucus, harassing and spasmodic cough, alteration in the voice, 
contraction of one pupil (sympathetic), and supraclavicular glandular 
enlargement in conjunction with esophagoscopy suggest diagnosis. This 
disease may run its entire course without dysphagia or eructation. 

Obstruction due to pressure from without, as from goitre, hyper- 
plastic mediastinal gland, aneurysm, or malignant tumor, is usually 
recognized as such, since because of the movability of the esophagus it 
is not compressed untill these tumors reach such size as to be recognized 
by the physical signs. Malignant mediastinal infiltration may by exten- 
sion involve the esophagus early and cause dysphagia before the original 
tumor is sufficiently developed to formulate a diagnosis. 

Polypi. — ^Polypi (adenofibromata) are rare. They usually grow from 
the upper extremity of the esophagus or from the pharynx, and occasion 
no symptom except dysphagia and, when the pedicle is long, attacks of 
dyspnea. 

Diagnosis should be made by examination with bougies, the laryngo- 
scope, and the esophagoscope. 

Diverticula of the Esophagus. — Diverticula of the esophagus commonly 
arise from the posterior wall of the pharyngo-esophageal junction at 
a point of normal weakness (constrictor fibers absent). The diver- 
ticulum is slow (many years) in development, ultimately forming a 



476 THE THORAX 

pouch projecting downward along the canal, and, when filled with food, 
compressing the latter. 

In its early stages, and at times through life, it is characterized by no 
other symptom than eructation of food, and can be distinguished from 
stomach rumination by examination of this food for gastric juice. 

When of sufficient development to mechanically interfere with swal- 
lowing, it is manifested by dysphagia, pain relieved by eructation of 
stinking food without gastric juice, tumor of the neck in case of a high 
diverticulum (not always), which can be emptied into the pharynx by 
external pressure. A bougie usually passes directly into the diverticulum 
and is arrested by its fundus. A second bougie passed beside the first 
readily slips into the stomach. 

Diverticula of the lower part of the esophagus, usually rising from 
the anterior surface near the brachial bifurcation, may be difficult to 
distinguish from dilatation secondary to cardiospasm. In each there 
may be slow onset, steady progression, dysphagia, pain, and eructation 
of large quantities of putrid but non-digested food with relief of 
pain. The opening into the diverticulum may be found or avoided 
at will by the use of an elbowed bougie or woven stomach tube. If 
two be passed in succession, after lodgement of one the other may pass 
by it and readily enter the stomach. On injection through these two 
bougies of a colored and a clear solution, one into the diverticulum, 
the other into the stomach, there will be no mixing of these two unless 
more has been poured into the diverticulum than it is capable of hold- 
ing. The ingestion of bismuth and mashed potatoes may enable a 
characteristic a:-ray picture to be taken. 

The use of the esophagoscope may be needful before diagnosis is 
made. Indeed, this may remain doubtful even after careful examination 
with that instrument. 



CHAPTER XVI. 

THE ABDOMEN. 

Contusion. — Contusion is followed by pain, shock, and vomiting. 
Exceptionally shock may be almost immediately fatal in the absence 
of demonstrable lesions. 

As a rule, the shock and pain are proportionate in their severity and 
persistence to the intra-abdominal lesion. Neither vomiting of blood 
nor its appearance in the stool is in itself diagnostic of gastric or intes- 
tinal rupture. 

The symptoms on which the diagnosis of rupture is based are severe 
and persistent pain, shock from which reaction takes place in the course 
of hours rather than minutes, tenderness to deep pressure, increasing 
rather than diminishing muscular rigidity, and the rapid development 
of symptoms of diffuse peritonitis. 

In distinguishing between hemorrhage and perforation, the greater 
pain of the latter, the more rapid development of peritonitis, and 
increased vascular tension with the onset of inflammation would be 
significant. 

A rapidly developing movable flank dulness may be elicited in severe 
hemorrhage, and often rectal tenesmus from accumulation of blood in 
the rectovesical peritoneal pouch. 

In certain exceptional cases, after the first transitory pain and perhaps 
vomiting, neither shock nor other signs of intraperitoneal trouble develop 
for many hours. These cases are characterized after the immune interval 
by the sudden outbreak of symptoms of acute perforative peritonitis. 
The stomachs of habitual drunkards may be ruptured by slight violence 
or even in the absence of this. Intestinal rupture from contusion is 
commonest in the upper part of the jejunum. 



PERITONITIS. 

Peritonitis, intestinal obstruction, and gastro-enteritis so commonly 
complicate surgical affections of the abdominal viscera that a knowl- 
edge of their diagnostic features, aside from the agents which cause 
them, is important. 

The peritoneum, a serous membrane about equal in area to that of 
the skin, exhibits an extraordinary power of both absorption and exuda- 
tion; the former is best developed in its diaphragmatic portion. The 
latter is expressed as a serous, fibrinous, or purulent effusion, or com- 
binations of these in accordance with the nature and progressive viru- 
lence of the exudative agent. 



478 THE ABDOMEN 

Peritonitis, almost never primary, with perhaps the exception of the 
pneumonic form observed mainly in children, is due to the extension of 
infection from the organs which this membrane covers. 

It may be acute or chronic, local or diffused. 

Acute Local Peritonitis. — Acute local peritonitis, usually incident to 
extension of inflammation from the appendix, gall-bladder, or Fallopian 
tubes, is characterized by persistent burning, stabbing, colicky pain, 
rapid in onset, at first referred to the umbilical region, later to the seat 
of inflammation, often with peripheral radiations or references. 

Tenderness at or about the seat of maximum inflammation is elicited 
by deep pressure, palpation, or by coughing or forceful breathing. 

There is local tympany and lessened or absent peristalsis in the por- 
tion of the gut involved, hence constipation and vomiting. 

The overlying muscles are persistently rigid. There is usually general 
tympany and tenderness, nausea, vomiting, and constipation. 

Fever and leukocytosis are usual. The pulse is hard and hurried. 

Acute Diffuse Peritonitis. — Acute diffuse peritonitis, when due to a 
suddenly developing cause, usually the rupture of an ulcerated or 
inflamed hollow viscus or of an abscess lying within the peritoneal 
cavity or in a part covered by it, is characterized by sudden violent pain 
of overwhelming intensity, attended with shock, vomiting, and general 
abdominal tenderness, shortly followed by wooden rigidity of all the 
abdominal muscles, absence of peristalsis, tympany, absolute constipa- 
tion, shallow thoracic respiration, and persistent vomiting. The fre- 
quently repeated vomiting becomes regurgitant in type, the patient 
spitting out brownish offensive fluid every few minutes. 

With the constitutional and local reaction against irritation and infec- 
tion, fever and leukocytosis develop. With fever there is a hurried, 
wiry pulse which, with the advent of tympany and overwhelming intoxi- 
cation, becomes rapid, intermittent, and almost or quite imperceptible 
at the wrist. 

Dorsal decubitus, with slightly flexed thighs and raised head and 
shoulders, is suggestive of the judgment of the nurse rather than the 
nature of the disease. Death from vasomotor paresis may occur without 
inflammatory reaction, the symptoms, aside from the agonizing pain, 
being those of profound shock. It is usually toxic, incident to septic 
absorption mainly from the bowel contents, peritonitis always occasion- 
ing paralysis of the intestinal muscles. 

On no single symptom can the diagnosis of acute peritonitis be form- 
ulated. The pathognomonic symptom group is severe pain, tender- 
ness, muscular rigidity, thoracic breathing, tympany, feeble or absent 
peristalsis, vomiting, and fever with hurried, wiry pulse and constipation. 
Very exceptionally, and usually significant of profound sepsis, the belly 
is flat and there is diarrhea. 

In diffuse peritonitis the appearance is always that of serious illness. 
The diagnosis of the terminal stage is of little service. 

Acute intestinal obstruction, especially when due to strangulation, 
is distinguished from peritonitis, in its early stages, by the absence of 



PERITONITIS 479 

fixation rigidity and the presence of exaggerated peristalsis. Later 
the conditions are combined. 

Pulmonary affections and pericarditis may cause severe pain referred 
to the abdomen, with tympany, vomiting, and constipation, but tender- 
ness is not best elicited on deep palpation, nor is there absent peristalsis 
nor pronounced or persistent rigidity; except in diaphragmatic pleurisy 
the abdominal respiratory movement is unaffected, while the hurried 
respirations in the one case and signs of local lesion in the other should 
at least suggest a diagnosis. • 

The abdominal pain of certain infections, such as typhoid, influenza, 
acute rheumatic fever, the exanthemata, or of angioneurotic edema, 
uremia, gout, ataxia, plumbism, or gastralgia, is accompanied by a 
history or other symptoms characteristic of each affection, nor is the 
convincing symptom-complex of peritonitis ever seen. 

Angioneurotic edema, often hereditary, usually beginning in child- 
hood, and characterized in its early development by the sudden appear- 
ance of edematous surface patches, may be characterized by visceral 
crises, strongly suggesting either obstruction or peritonitis. There is 
pain, which may be shocking in intensity, vomiting which often contains 
blood, and later diarrhea. 

The abdomen is usually retracted. There is no true muscular rigidity, 
nor is there characteristic tenderness to deep pressure. Exceptionally 
these symptoms may be associated with tympany and intestinal paresis, 
in which case the history should be carefully considered in making a 
diagnosis, and search of the surface should be made for purpuric spots. 
Similar crises are noticed as prodromal of the erythematous skin diseases. 
Inflammation of the abdominal wall is characterized by the local 
and usually readily demonstrable symptoms of this affection, by the 
fact that tenderness is located in the wall and not beneath it, and 
by the absence of the symptoms of peritoneal involvement. If sub- 
aponeurotic inflammation be complicated by local peritonitis, the 
recognition of the combined lesions may be difficult. 

Rheumatic neuralgia of the abdominal muscles produces both tender- 
ness and rigidity, which usually involves the whole of at least one side, 
is distinctly superficial, and is aggravated by movement. In this affec- 
tion, as also in neuritis, cutaneous hyperesthesia is well marked, and 
in neuritis points of nerve tenderness can be demonstrated. Peristalsis 
is unaffected, there is no meteorism; unless the diaphragm be directly 
involved, it moves freely and muscular tenderness is relieved by warm, 
broad pressure. 

Perirenal inflammation exhibits tenderness, best elicited by pressure 
in the costovertebral angle. The pain is in the renal region and is 
referred along the lower intercosto-abdominal nerves to the abdomen. 
It customarily radiates along the course of the ureter to the bladder. 
Though one side of the abdomen may be rigid, muscular fixation is 
most marked over the renal region. 

Spinal caries, aneurysm of the abdominal aorta, spondylitis deformans, 
and acute osteomyelitis of the spine may occasion pain and rigidity 



480 THE ABDOMEN 

which in themselves may simulate peritonitis but are unaccompanied 
by other gastro-intestinal symptoms. 

Arteriosclerosis is exceptionally characterized by crises of pain which 
may be attended by vomiting and tympany. Inflammatory symptoms 
are absent and nitrites may give relief. 

Hysterical pseudoperitonitis may present many of the signs of grave 
inflammation, including in rare instances fecal vomiting, which, how- 
ever, is likely to be attended by a violent retching. Neither fever nor 
leukocytosis is present; nor is the facies that of profound illness. 
The onset is unattended by the shock and vasomotor paresis of true 
fulminant peritonitis, and the symptoms will be found lacking in proper 
relationship to each other and often markedly influenced by suggestion. 

The non-infectious forms of acute diffuse peritonitis, such as are 
incident to hemorrhage, as from a ruptured extra-uterine pregnancy, 
or extravasation of sterile urine, exhibit typical symptoms. The diag- 
nosis as to cause must be based on the history and on findings other 
than those incident to the inflamed peritoneum, though the form of 
the affection is less fulminant in development and pursues a slower 
course than that characteristic of the septic type. The differential 
diagnosis should be made by celiotomy. 

Chronic Peritonitis. — Chronic peritonitis, which may be local or diffuse, 
may be almost symptomless except for a serous exudate, or may be 
characterized by irregularly recurring subacute or acute attacks, con- 
valescence from such attacks never being complete. Even during 
acute exacerbations pain, tenderness, and rigidity are never as pronounced 
as in acute pyogenic inflammation, and fever and leukocytosis are slight 
or wanting. Constipation often alternates with diarrhea and partial 
obstruction with muscular hypertrophy of the intestinal wall, and exag- 
gerated peristalsis is common. 

Chronic peritonitis may be due to tuberculosis (common), carcinoma 
(less common), actinomycosis (rare), or serositis (rare), and may exhibit 
either a serous or fibrinoplastic exudate. 

Tuberculous Peritonitis. — ^Tuberculous peritonitis, especially an affec- 
tion of children, is characterized chiefly by cachexia and fluid distention 
of the abdomen, which in the serous type may be painless. In the 
fibrinous type, recurring colicky pains with tenderness are common, 
and irregular nodular masses may be felt due to tuberculoma of the 
omentum or the mesenteric glands. In the absence of mixed infection 
fever and leukocytosis are but slightly marked. 

Chronic fibrinous peritonitis, often most pronounced about the tubes 
or appendix, sometimes confined to these regions, is, if tuberculous, sec- 
ondary to involvement of these structures. The symptoms may be 
those of mechanical obstruction caused by contracture and adhesions 
rather than those of inflammation. 

Associated tuberculous lesions elsewhere, a positive tuberculin test, the 
injection of a susceptible animal with aspirated fluid, direct inspection 
through ah incision, and microscopic examination are the diagnostic 
means. ] . . 



INTESTINAL OBSTRUCTION 481 

Diffuse carcinoma of the peritoneum, usually secondary, is char- 
acterized by a serosanguineous exudate, and in the terminal stages by 
distinct nodulations. 

Diagnosis is suggested by the history of a primary lesion, rapidity 
of progress, the profound and progressive deterioration in general 
health, and by exploratory operation. 

Multiple serositis is characterized by chronic inflammation of the 
pericardium, pleura, and peritoneum, with serous exudate into the cavity 
of each of these structures. 



INTESTINAL OBSTRUCTION. 

Intestinal obstruction may be due to a paralytic condition of the 
bowel muscle, in which case it is termed dynamic, or to occlusion of 
its lumen, in which case it is termed mechanical. As opposed to peri- 
tonitis, intestinal obstruction, except in its dynamic form, is char- 
acterized by exaggerated peristalsis, straining and propulsive vomiting, 
and absence of fixation rigidity of the abdominal wall. The two con- 
ditions are often combined, since dynamic ileus is an almost invariable 
accompaniment of acute diffuse peritonitis, and peritonitis is equally 
certain to follow unrelieved acute obstruction. 

Djmamic Ileus. — Dynamic ileus is most typically exemplified as it 
occurs in acute diffuse peritonitis. It may follow operation, in the 
absence of inflammation, as a consequence of rough or prolonged 
manipulations or of peritoneal chill. Exceptionally it develops after 
abdominal contusion, or is caused by excessive gaseous distention 
or splanchnic or spinal nerve degeneration. It is a common terminal 
condition, often directly causative of death in systemic diseases such 
as pneumonia, nephritis, meningitis, and typhoid fever. 

In its mild and transitory form it follows all abdominal operations, 
probably incident to a traumatic non-infective peritonitis, accompanies 
renal, biliary, ovarian, or pancreatic colic, indeed, any acute intraperi- 
toneal or juxtaperitoneal congestion or inflammation sufficiently pro- 
nounced to cause severe pain. It is then characterized by tympany, 
constipation, and absent or feeble peristalsis. The vomiting, if present, 
is of reflex pain origin and is not persistently recurring, nor do the 
symptoms of toxic absorption develop. 

Characteristic symptoms of acute dynamic ileus are: absent peristalsis; 
progressive, uniformly distributed abdominal tympany, marked by a 
tense, rounded belly wall, in which individual intestinal coils cannot 
be felt; shallow, hurried respiration, because of upward pressure; rapid, 
weak, irregular heart action, caused at first by pressure, later by toxemia ; 
profuse, persistently recurring, regurgitant vomiting of an offensive 
thin fluid, made brown or black by the presence of minute coagula; 
absolute constipation to both feces and flatus; and pain which, aside 
from that of the causative factor, is not severe, is not colicky in char- 
acter, and is much bettered by the evacuation of gas. 
31 



482 THE ABDOMEN 

The constitutional symptoms are those of toxic absorption. The 
urine is scanty, concentrated, and contains an excess of indican. When 
the condition, as is usually the case, is caused by peritonitis, the pro- 
nounced pain, tenderness, rigidity, and often fever and leukocytosis of 
this condition are present. 

Incident to the enormous distention which follows hard upon paralysis 
of the bowel muscle and the consequent angulation of the gut, the 
dynamic ileus quickly becomes mechanical. 

Mesenteric thrombosis and embolism depart from the type of strangu- 
lation ileus in the fact that, though they may begin with agonizing or shock- 
ing pain, vomiting, tenderness, and local meteorism, one or more profuse 
blood-stained passages are common and free fluid is early developed in 
the peritoneal cavity; occasionally a palpable blood tumor can be felt 
between the layers of the mesentery. In the embolic form of the affection 
there is usually valvular disease of the heart, and emboli may develop in 
other parts of the body, or they may have previously manifested them- 
selves. 

Mechanical Ileus without Strangulation. — This differs in symptoma- 
tology from that accompanied by strangulation in its less sudden, painful, 
and shocking onset and the much slower development of symptoms 
of profound intestinal toxemia and ultimate diffuse peritonitis. The 
absolute constipation, the recurring explosive vomit, the exaggerated 
peristalsis, and the progressive tympany are characteristic. 

Fecal vomiting in any form of intestinal obstruction is a terminal 
symptom, hence of little use in framing a serviceable diagnosis. 

Obturation Ileus. — Obstructive ileus, or mechanical obstruction of the 
gut by a plug or mass within its lumen, is in its mild form usually due 
to fecal impaction which occurs in anemic patients who have long been 
suffering from chronic intestinal catarrh. The onset is gradual, it is 
preceded by constipation which, though obstinate, is not inveterate, often 
by constipation alternating with diarrhea. When the blockage becomes 
complete, distention and hyperperistalsis are both marked, and vomiting 
is recurrent and the constipation absolute. The usual position of fecal 
impaction is in the rectum where it can be felt by digital examination. 
If in the colon, a doughy mouldable tumor may be detected. 

Obturation by gallstone (rare) gives a preceding history of crippling 
peritonitis in the gall-bladder region. 

Obstruction due to foreign body may be diagnosticated by the history 
and at times by the skiagraph. 

Complete obstruction due to stricture formation or to pressure of a 
tumor or infiltration in the bowel wall, or external to it, is preceded by a 
history of repeated attacks of partial obstruction, and often before this 
the symptoms of the causative lesion. Since the obstruction is slow in 
its development, the muscular coat of the bowel lying above the seat of 
narrowing hypertrophies, and, if time be given, the gut dilates. The 
peristalsis in this segment is usually both palpable and visible, and, par- 
ticularly in the case of stricture, is attended by annoying borborygmus. 

Obstruction due to angulation of the bowel, incident to adhesion, 



INTESTINAL OBSTRUCTION 483 

corresponds in type to obstruction without strangulation. The sudden 
painful onset is without pronounced shock. The major complaint is of 
severe recurring colicky pain, and often vomiting, usually with remissions 
or complete intermissions, since the obstruction is, as a rule, not per- 
sistently complete. Except when the sigmoid is involved, the history of 
a previous operation or a local peritonitis is usually obtained. This 
form of ileus is frequently observed as an early sequel to abdominal 
operation, particularly when drainage has been needful. 

Strangulation Ileus. — Mechanical obstruction of the bowel lumen 
may be complicated by a devitalizing constriction of its bloodvessels, 
in which case it is called strangulation ileus. This is usually due to 
constriction of the gut by a hernial orifice. A similar constriction may 
be caused by fibrous bands incident to a former peritonitis, Meckel's 
diverticulum, appendicular or omental adhesions or openings in the 
mesentery or omentum. 

With the onset of the symptoms of strangulation ileus, especially if 
these come on shortly after a violent muscular effort, the hernial orifices 
should be carefully examined; this is especially important if there is a 
history of previously existing hernia. In the case of strangulated iliac 
or obturator hernia there will be no tumor, but local pain and tenderness 
and radiations of pain may be suggestive. 

In the absence of the signs of external hernia the possibility of dia- 
phragmatic, duodenojejunal, and retroperitoneal herniae should be 
considered. The chest signs of diaphragmatic hernia may be character- 
istic (see p. 507). Strangulation of other internal hernise cannot be 
diasjnosticated as such. 

The characteristic symptoms of strangulation ileus are sudden, violent, 
agonizing, general abdominal pain, usually associated with shock, imme- 
diate nausea, and vomiting, the latter persistently recurring, and a 
temporary diminution or complete cessation of peristalsis (reflex). 
With recovery from shock peristalsis becomes reestablished and palpably, 
audibly, and sometimes visibly exaggerated, and there is often an urgent 
desire to defecate, the efforts producing at the most one or two bowel 
movements. 

Tympany shortly develops, demonstrable first in the strangulated gut 
segment, later becoming general above the point of obstruction, the gut 
below remaining undistended. The shocking pain of onset becomes 
more bearable and colicky in nature, exhibiting remissions and exacer- 
bations incident to peristalsis. Constipation shortly becomes absolute. 
Vomiting is recurring, straining, and propulsive at first; later, with the 
onset of peritonitis, it becomes regurgitant and effortless. The constitu- 
tional symptoms are those of intestinal toxemia. The onset of gangrene, 
often characterized by a temporary diminution of pain, is followed by the 
rapid development of the symptoms of diffuse peritonitis. 

At times strangulation ileus in onset and progress corresponds so 
closely with that characteristic of obturation that a diagnosis is formu- 
lated only on operation or by the development of acute diffuse peri- 
tonitis. 



484 THE ABDOMEN 

The distinction between internal strangulation and acute diffuse 
peritonitis from perforation is dependent upon the prompt reaction from 
shock in strangulation, the exaggerated peristalsis incident to this 
recovery, the explosive vomiting, and the absence of general abdominal 
rigidity and extreme tenderness. The preceding history is usually 
helpful. During the primary shock period a differential diagnosis cannot 
be made. 

In distinguishing between strangulation and the reflex dynamic ileus 
incident to pulmonary, renal or cardiac affections, spinal degeneration, 
particularly ataxia, arteriosclerosis, renal and biliary colic, aside from 
the symptoms particularly characteristic of each of these conditions, the 
moderate primary tympany usually not actively progressive, the feeble or 
absent peristalsis, and the cessation of constantly recurring vomiting, 
with the subsidence of the agonizing pain, are characteristic. Moreover, 
purgatives given in full doses are usually efficient. In acute mechanical 
obstruction their one useful purpose is to so aggravate symptoms that 
previously unwilling patients welcome surgical treatment. 

Intussusception, or invagination of one portion of the gut within 
another, usually downward and in the ileocolic region, essentially an 
affection of infancy and childhood, and the usual cause of acute intes- 
tinal obstruction at this age, is frequently caused by a polyp, sometimes 
follows abdominal trauma, and is an occasional sequel or accompani- 
ment of diarrhea and dysentery. It may develop in the midst of perfect 
health. 

Because the bowel is usually not completely occluded and the constric- 
tion not immediately devitalizing, intussusception departs from the type 
of strangulation in that it is usually characterized by tenesmus and 
straining and the frequently repeated passage of bloody mucus with a 
fecal admixture; the primal shock is slight, the vomiting not constantly 
recurring, and meteorism is slow in development. Colicky pain with 
remissions of minutes or hours and exaggerated peristalsis, are usually 
associated with the detection of a soft tumor placed along the course of 
the colon. At times the invagination can be felt by rectal examina- 
tion. 

When there is no palpable tumor, the diagnosis from acute or sub- 
acute gastro-enteritis should be based upon the complete absence of 
stools, or the passage of bloody mucus containing at most a very slight 
fecal admixture. 

Acute Volvulus. — Acute volvulus, or twisting of the intestine upon its 
mesentery as a base, may involve nearly the whole of the small gut, or one 
or more loops of it. Usually it is observed in the sigmoid of constipated 
elderly people, and is distinguished in addition to the symptoms common 
to all forms of strangulation by a rounded, tympanitic, quiet tumor, 
which may be felt in the left flank or may extend above the umbilicus 
and beyond the median line. There is usually absolute constipation, 
pronounced tenesmus, and diminished capacity to rectal injection. The 
symptoms may be sudden in onset or may have been preceded by recur- 
ring attacks of partial obstruction. 



GASTRO-ENTERITIS 485 



GASTRO-ENTERITIS. 



Catarrhal inflammation of the stomach and bowels frequently simulates 
surgical affections of these organs and complicates many of them. 

Acute Gastritis. — Acute gastritis is characterized by epigastric tender- 
ness, distress or pain aggravated by eating, nausea, eructations and 
vomiting of undigested food or of mucus sour from butyric, lactic, or 
other acid fermentation unless there be bile admixture. In severe cases 
the vomitus contains blood. Headache, constipation, foul breath, and 
coated tongue are associated symptoms. Children exhibit fever. 

Acute Enteritis. — Acute enteritis is characterized by colic, which may be 
agonizing in intensity, but is rarely accompanied by shock, general 
abdominal tenderness, exaggerated peristalsis, and diarrhea, excepting 
when the process is confined to the duodenum. The evacuations are 
foul, bilious, mucoid, at times bloody, and are copious and recurring in 
proportion to the colonic involvement. Moderate tympany is usual, and 
is least marked when the diarrhea is profuse. The same, with some 
modification, is true of fever. 

When the inflammation is confined to the duodenum it is not infre- 
quently associated with jaundice unattended by colic and usually of 
brief duration (days). The greatest tenderness is above and to the 
right of the umbilicus. It is from this source that infection of the 
biliary passages usually arises. Ileocolitis is characterized by pain 
and tenderness, most pronounced in the right iliac fossa and along the 
course of the colon, and copious and frequent fluid passages, containing 
large quantities of mucus. The complication of appendicitis, which is 
not unusual, is characterized by the substitution of constipation for 
diarrhea, of fixation rigidity by protective contraction of the right rectus 
muscle. 

Sigmoiditis and proctitis are attended with pain, tenderness in the left 
iliac fossa, with burning, teasing, and often tormenting tenesmus resulting 
in small mucoid, frequently bloody evacuations. The diagnosis can at 
times be made by a proctoscopic examination. 

Chronic gastritis and enteritis are usually associated. The combined 
affection is characterized by eccentricities of appetite or its complete loss, 
belching and rectal passage of flatus with much borborygmus, or even 
vomiting, particularly in the morning or some hours after the ingestion 
of food. Except in that form of chronic gastritis accompanying ulcer, 
or in certain neuroses, hydrochloric acid is either diminished or absent. 
In chronic gastritis constipation is usual. 

In chronic colonic catarrh, diarrhea is the rule. The stools are offen- 
sive and contain mucus. Pain and tenderness may be absent, insignifi- 
cant or periodically harassing. The colic is likely to be recurring. The 
tenderness can usually be elicited by deep palpation in the region of 
maximum involvement. There is usually gastric and intestinal tym- 
pany, excepting shortly after attacks of vomiting and purging, and the 
noisy belly of an active peristalsis working on-gaseous and liquid contents. 



486 THE ABDOMEN 

Foul breath, flabby, coated tongue, chronic pharyngitis, and the general 
systemic condition incident to chronic intestinal toxemia are observed. 
The urine is diminished and contains an excess of indican. 

Chronic obstruction from any cause is attended with the symptoms 
of gastritis or enteritis dependent on its position, together with those 
of interference with the onward passage of the intestinal contents. 
Obstinate constipation alternating with diarrhea, and associated with 
local pain and tenderness, and a neurasthenic condition are highly char- 
acteristic of the association of symptoms in the case of chronic sigmoid- 
itis dependent on redundancy and angulation. 

Before assigning a surgical cause to gastro-enteritis it is necessary to 
eliminate the general medical causes of this affection, among which may 
be mentioned dietetic errors characterized by simple catarrh, cholera 
morbus, or ptomain poisoning, local expressions of the exanthemata, 
gout, purpura, scurvy, uremia, generally associated with constipation, 
sepsis of any kind, or intestinal parasites. 

Gastro-enteritis dependent upon infiltration, ulcer, visceral prolapse, 
cicatricial contracture, or partial obstruction from any cause is distinctly 
surgical and calls for surgical treatment. The symptoms of the causative 
factor can usually be found if carefully sought for. It should be remem- 
bered that chronic gastro-enteritis may be characterized by abdominal 
pain, nausea, vomiting, or diarrhea. 

ABDOMINAL TUMORS. 

The diagnosis of abdominal swelling is dependent upon the point of 
origin of such swelling, its nature, whether gaseous, fluid, or solid, and 
in the latter case whether hyperplastic, inflammatory, or neoplastic; its 
mobility, its extent, its relation to systemic conditions or organic lesions. 

In forming an opinion the condition of general nutrition, the rapidity 
of development, antecedent disease, and the age of the patient are all 
factors to be considered, nor can the examination be regarded as complete 
without a record of the urine, blood, the daily temperature range, the 
pulse rate, and often the data derived from fecal examination. 

In general terms acute or subacute abdominal inflammation is char- 
acterized, in addition to swelling, by the blood changes and tempera- 
ture reaction which are incident to this condition in other parts of the 
body. These symptoms, when marked, associated with local tenderness 
and, in cases of peritoneal or intraperitoneal involvement, muscular 
rigidity establish the diagnosis. 

Chronic inflammation is, however, at times characterized by such 
slightly marked constitutional and local symptoms of this condition as 
to be entirely misleading. Under such circumstances the tumor is the 
major symptom, together with toxic anemia and perhaps slight tempera- 
ture fluctuations not greater than are frequently observed in malignant 
disease. 

The diagnosis must often be made by operation. Sometimes even then 
it is decided only by microscopic examination of the tissue removed. 



ABDOMINAL TUMORS 487 

The detection of intra-abdominal tumors by palpation is particularly 
diflficult in patients with muscular and rigid belly walls, in those who are 
chronically tympanitic, in those cursed by an enormous adipose panniculus, 
or in those suffering from ascites. 

Examination for abdominal tumor should be preceded by a thorough 
evacuation of the bowels and by emptying the bladder. 

Neoplasms involving the parietes are usually accidentally discovered 
by the patient, and are readily detected by inspection or palpation, or 
both. The true nature of such growth is usually determined by opera- 
tion, though the rapidity of grow^th and age incidence are both important 
factors in framing an opinion. 

The presence of intra-abdominal neoplasms is usually not suspected 
until by their growth they produce pressure symptoms, as a rule those 
of chronic intestinal obstruction. Occasionally they are detected by 
palpation before such pressure symptoms develop. 

Cysts, if tense and thick-walled, cannot be distinguished by palpation 
from solid tumors, though, when they reach large size, they usually 
exhibit distinct fluctuation. ^^Tien soft walled and flaccid, their detection 
may be quite impossible except by means of an exploration. 

Swellings Limited to the Abdominal Wall. — Such swellings are 
characterized by their superflcial position, obvious both to palpation 
and inspection, and the absence of symptoms referable to involvement 
of internal organs. If the abdominal w^alls are lax, the mass can be 
grasped between the thumb and finger or between the two hands, and 
thus differentiated from the abdominal contents. They have neither 
respiratory nor other movement independent of the abdominal wall, 
except in the case of hernia. Contraction of the abdominal muscles 
does not flatten the tumor or cause it to disappear, but often accentuates it. 

From an intra-abdominal tumor fixed to the parietal peritoneum the 
distinction may be difficult. 

Diffuse swelling of the abdominal wall is rarely limited to this region, 
though it may be most marked here. The umbilicus is usually drawn in. 

The diffuse swelling due to obesity does not pit on pressure, gives 
the characteristic finely lobulated sensation of fat to the palpating fingers, 
and exhibits the characteristic transverse folds at the umbilicus and just 
above the pubes. 

Edema pits on pressure and, except as an expression of local inflam- 
mation, is not confined to the abdominal wall. 

Emphysema exhibits crackling and pitting on palpation, and is asso- 
ciated w^ith fractured rib or gangrenous cellulitis. 

Cellulitis, usually due to extravasated urine, is preceded by a history 
of urethral obstruction, is attended by a pronounced edematous scrotal 
swelling, is limited in its downward extension by Poupart's ligament, pits 
on pressure, and exhibits the constitutional symptoms of profound sepsis. 

Circumscribed Swellings of the Abdominal Wall.— The commonest 
parietal swelling is that due to hernia usually occurring, in the absence 
of preceding wound or severe trauma, in the inguinal or umbilical region 
or in the midline above or below, the umbilicus, and exhibiting the char- 



488 THE ABDOMEN 

acteristic features of this condition (see p. 500). The midline hernise 
are usually small (the size of a finger tip), and can be distinguished from 
a projection of the subperitoneal fat through the linea alba only by 
operation, since either condition may be reducible and give slight 
impulse on coughing. These hernise often cause persistently recurring 
gastro-intestinal symptoms. 

Abscess of the abdominal 'parietes, if acute, presents the characteristic 
symptoms of this condition. It is usually secondary to intra-abdominal 
suppuration, particularly of the appendix, and is preceded by symptoms 
characteristic of local suppurative peritonitis. 

Spinal osteomyelitis may lead to extensive pus formation in the 
abdominal walls. 

Tuberculous bone infection usually causes a cold abscess, the dominant 
symptom of which is a fluctuating, non-sensitive, slowly progressive, 
painless tumor. A favorite seat of pointing is in the lumbar region. 

Actinomycosis due to direct extension from the intestine, and noted, 
as a rule, in the ileocecal region, is characterized by the progressive 
involvement of the parietes in an induration which softens and discharges 
pus and which contains the ray fungus. 

A similar condition may result from tuberculosis, nor can the diagnosis 
be made except by microscopic examination and associated manifesta- 
tions of the disease. 

Rupture of the Abdominal Muscles. — ^Rupture of the abdominal muscles, 
commonly involving the rectus, and observed in the late course of diseases 
such as typhoid, though it has been reported in healthy individuals as 
the result of severe strain, is characterized by sudden severe pain, rapid 
(minutes) tumor formation which may reach great size, and the detec- 
tion of a break in continuity by palpation, though intraparietal bleeding 
in the absence of the last sign would be suflSciently characteristic. 

Syphilis. — Syphilis in the form of gumma (rare) closely simulates 
malignant infiltration. A history of infection and the presence of asso- 
ciated lesion, or the evidence of such in the past, and the application of 
the therapeutic test are diagnostic helps. 

Lipoma. — Of the benign tumors, lipoma is the one most frequently 
encountered; unmistakable in its superficial form, the diagnosis is 
suggested by its extremely slow growth (years) and absence of symp- 
toms other than bulk. When subaponeurotic, the diagnosis is more 
difiicult, but would be suggested by its softness and its gradual develop- 
ment. 

Lipomata at the midline are generally above the umbilicus. They 
originate in the preperitoneal fat, projecting along the course of a blood- 
vessel through the aponeurosis until they become subcutaneous. These 
lipomata are often reducible; they not infrequently drag a pouch of 
peritoneum with them, thus forming a true hernia. 

Fibroma. — Fibroma, single or multiple, developing in the lower quad- 
rants, particularly from the rectus sheath of women who have borne many 
children, and often first noticed during pregnancy, are characterized by 
their hardness and slow (years) growth. 



ABDOMINAL TUMORS 489 

Phantom Tumor. — Phantom tumor observed in hysterical women, 
usually near the midline below the umbilicus, and due to muscular 
contraction, forms a smooth, non-sensitive mass, which is not flattened 
or made less conspicuous by muscular contraction and does not move 
independently of the muscle. It disappears during deep ether anesthesia. 

Sarcoma. — Sarcoma, at times of traumatic origin, usually apparently 
causeless, is marked by its rapid growth (months) . The early diagnosis 
should be based upon the prompt removal and microscopic examination 
of a recently discovered and steadily progressive parietal tumor. 

Carcinoma is usually secondary. 

Cyst of the urachus, due to a persistent patulousness of a part of this 
canal, is most frequent in males. A fixed midline tumor between the 
navel and symphysis, sometimes varying in size proportionate to the 
fulness of the bladder, exceptionally reaching huge size, is characteristic 
of this condition. 

Hydatid cyst (rare), noted in the midline below the umbilicus or in 
the lumbar region, forms a rounded, slow growing (years) tumor, often 
solid to palpation. The diagnosis is usually not made until operation, 
though fluctuation, hydatid thrill, the finding of booklets in the evacuated 
fluid, and the precipitin reaction would be characteristic. 

The Umbilicus. — ^The umbilicus, the scar of the obliterated umbilical 
cord, is weakest at its upper part (scar of the obliterated umbilical vein). 
Its lower part is strengthened by the remains of both the' urachus and 
umbilical arteries. 

Pouting umbilicus is usually due to hernia or ascites. It is occasion- 
ally caused by prolonged gaseous distention. 

Congenital anomalies occur in the form of failure of the lateral plates 
to properly come together at the midline, thus leaving the abdominal 
contents w^ithout muscular or fascial covering, and resulting in congenital 
umbilical hernia; also there may be persistence of the urachus, con- 
stituting a urinary fistula, or of the vitelline duct, constituting a fecal 
fistula. 

Persistent vitelline duct is characterized by a pouting of mucous mem- 
brane at the umbilicus which closely resembles a small prolapsed anus. 
Through the opening feces may or may not be discharged. In the former 
instance the diagnosis is absolute. In the latter the affection must be 
distinguished from patent urachus. 

Persistent urachus results in the formation of a midline cyst which 
usually bulges somewhat at the umbilicus as well as below it, or, if a 
fistula or pervious urachus is present, it is characterized by a leakage of 
urine from a small opening in the lower part of the umbilical scar. 

Myxoma may occur in the umbilical scar of infants and produce a 
good-sized, soft, non-inflammatory mass. 

Lipoma, sarcoma, and gumma occur at the navel. The last named, 
when it ulcerates and becomes indurated, must be differentiated from 
malignant tumor by the history, associated lesions or their scars or pig- 
mentations, and the therapeutic test. 

Carcinoma of the navel may originate at the umbilicus or may be 



490 THE ABDOMEN 

secondary to cancer of the stomach, intestine, or liver, of which it often 
may be taken as evidence. This may be due to direct extension or 
metastasis along the lymphatics. The diagnosis is made by incision 
and microscopic examination of a fragment of tissue. 

Inflammatory infiltration, abscess, and eczema, particularly noted in 
the uncleanly, exhibit their characteristic symptoms at the umbilicus. 
Diagnosis is not difficult. 

General Intra-abdominal Swellings.— Tympanites.— Tympanites, or 
gaseous distention of the intestines, when sufficiently pronounced and 
persistent to constitute a surgical affection, is incident to a paresis 
of the muscular coats of the stomach and bowel, allowing of a dilata- 
tion so great as seriously to interfere with the functions of both respira- 
tion and circulation. The full, rounded abdomen, exhibiting the 
pseudorigidity of tension, the obliteration of anatomical irregularities 
of the surface, universally tympanitic even well up into the thorax, 
and the associated dyspnea, costal breathing, and in hyperacute cases 
pulse hurry, are characteristic. 

Tympany in its congenital form appears in Hirschsprung's disease, 
or idiopathic dilatation of the colon, and may be so marked as to 
overdistend the entire abdomen, pushing the other hollow viscera 
aside. 

Either the stomach or the sigmoid, if greatly distended, produces a 
degree of tyfnpany quite similar to that of general gastro-intestinal 
paresis. 

Diffuse Peritoneal Effusion. — ^Diffuse peritoneal effusion, when it 
reaches such a degree as to interfere with the respiratory or circulatory 
functions, becomes a surgical affection independent of its cause. 

These diffuse effusions are characterized in their early development by 
a globular belly, peripherally dull on percussion, but resonant about the 
navel. Change in the percussion note from dull to resonant occurs on 
shifting the patient's position. Fluctuation may be felt in one flank 
when the other is jarred. In extreme cases the umbilicus forms a knob- 
like projection. 

The effusion may be serous, serofibrinous, or purulent. 

Ascites, or serous effusion, if unattended by general dropsy, is usually 
dependent upon obstruction to the portal circulation or tuberculous 
peritonitis. 

Atrophic cirrhosis of the liver, in its terminal stage, is the common 
cause of portal obstruction in adults. It is characterized by a small 
liver, often not demonstrable as such until the fluid has been withdrawn, 
and a characteristic preceding history. 

The portal obstruction caused by multiple serositis, or Pick's disease, 
is characterized by enlargement of the liver and spleen, adhesive peri- 
carditis, heart enlargement and usually valvular disease, pleural effu- 
sion, and marked ascites, which may be tapped repeatedly without 
deterioration of the patient's condition. The latter fact helps to distin- 
guish it from atrophic cirrhosis. 

Cancer of the liver and of the head of the pancreas may produce 



ABDOMINAL TUMORS 491 

similar symptoms. The affection is rapidly progressive, other pressure 
symptoms usually develop, and, if the liver be involved, the tumor 
often can be felt. 

In diffuse carcinomatosis the fluid removed by tapping is often 
blood-stained and contains cancer cells. 

Tuberculous peritonitis, commonest in the first three decades, the 
usual cause of ascites in children, may be without symptoms other 
than the swelling, or may exhibit slight rigidity and tenderness to press- 
ure. In any form it is attended with emaciation, irregular fever, pulse 
hurry, and absence of leukocytosis. The fibrous or adhesive variety 
is characterized by slight serous effusion and the formation of demon- 
strable masses due to adhesion of the intestinal coils and thickening 
and rolling up of the omentum. The ulcerative variety runs a rapid 
course and forms a purulent exudate which is nearly always localized. 

Ascites attended with demonstrable edema is usually secondary to 
disease of the heart or kidney. It may also be an expression of pro- 
found anemia. 

The distinction between diffuse peritoneal effusion and ovarian cyst 
is based on the midline dulness and fiank resonance of the latter con- 
dition, the corroborative results of vaginal examination, and the com- 
paratively slight difference in the area of percussion dulness and reso- 
nance incident to change in posture. An enormous hydronephrosis 
should give a suggestive previous history, nor does the fluid show the 
same mobility as that of diffuse peritoneal effusion. 

Diffuse Blood Effusions. — Diffuse blood effusions, usually traumatic, 
postoperative, or incident to rupture of ectopic gestation, are character- 
ized by the symptoms and physical signs of grave hemorrhage, rapidly 
formed movable dulness in the flanks, pain, tenderness, tympany, and 
often by the desire to urinate and to defecate. 

Localized Intra-abdominal Swellings.— SweUings of the midline 
or near it, if fixed, are usually retroperitoneal and neoplastic in origin, 
those of the upper and lower right quadrant are usually inflammatory, 
and those of the upper and lower left quadrant are usually neoplastic, 
while those of the lumbar region are, as a rule, renal, perirenal, or 
spinal in origin, and either inflammatory or neoplastic. To these rules 
there are many exceptions. 

Midline Swellings. — Midline swellings include those of the retro- 
peritoneal tissues, the body of the pancreas, the left lobe of the liver, 
the fundus of the stomach, the transverse colon, the omentum, the 
small intestines, the mesentery, the bladder space, and the uterus. 

The retroperitoneal midline swellings, if they reach conspicuous 
size, are usually of the lymphatic glands and neoplastic; sometimes 
they are inflammatory. Aortic or iliac aneurysm appears near the 
midline, as do lipomata and lymphatic, chylous, serous, dermoid, and 
hydatid cysts. 

The retroperitoneal origin of the swelling is suggested by its deep 
seat, though on light palpation it may seem superficial, its slight or 
absent mobility, often its distinct conveyance of aortic pulsation, the 



492 THE ABDOMEN 

obscuring effect incident to gaseous distention of the intestines, and 
its pressure effects as shown by edema of the lower extremities, pain 
radiating downward, gastro-intestinal disturbances, and emaciation. 

Acute inflammatory affections of the midHne retroperitoneal space 
are distinguished by the local and constitutional symptoms of inflam- 
mation rather than by those of tumor. 

Tuberculous inflammation exceptionally forms a tumor either due 
to cold abscess, secondary to bone involvement, or incident to tuber- 
culous adenitis; other and more pronounced symptoms of the tubercu- 
lous process are usually present. 

Malignant infiltration, commonly sarcomatous, exceptionally pri- 
mary, usually secondary to involvement of the testicle, ovary, or other 
organ contributing lymph vessels to the postperitoneal lymphatic chain, 
causes a rapidly growing (months) nodular tumor which usually pre- 
sents the typical characteristics of postperitoneal growths. Because of 
their great vascularity and of the pressure they exert upon the artery, 
these growths exceptionally give both bruit and expansile pulsation, 
making, in the absence of a primary peripheral focus, a non-operative 
differential diagnosis difficult, if not impossible. 

Retroperitoneal cysts (rare), if they reach large size, tend to grow 
between the mesenteric layers. Though their symptomatology con- 
forms to that of the retroperitoneal growths, and they are obscured by 
inflation of the gastro-intestinal canal, the diagnosis generally has been 
made at operation. 

Postperitoneal lipoma grows forward between the mesenteric layers 
slowly (years), forming a large, usually soft, semifluctuating tumor, 
giving midline dulness and peripheral resonance, and by its pressure 
causing pain, gastro-intestinal disturbance, and emaciation. The dis- 
tinction from postperitoneal cyst is usually made by operation. 

Aneurysm of the aorta or the iliac arteries, or of any of the large 
branches near their point of origin, forms a postperitoneal swelling 
which, when it becomes of palpable size, usually exhibits the character- 
istic symptoms of this affection. Exceptionally the distinction from 
vascular neoplasm may be difficult. 

Swellings of the body of the pancreas appear as midline tumors 
in the epigastric region. They are distinguished from intraperitoneal 
tumors by their fixation, conveyance of aortic pulsation, and obscuration 
by gastric inflation. The induration of chronic pancreatitis may be 
detected in thin persons. Pancreatic cysts present anteriorly either 
above or below the stomach. Cancer of the body of the gland forms 
an elongated nodular tumor, which cannot be distinguished by palpa- 
tion from a similar infiltration of the posterior stomach wall. 

Effusion of blood or serum into the lesser peritoneal cavity, usually 
secondary to acute hemorrhagic pancreatitis, forms an epigastric mid- 
line swelling usually masked by the gastric distention, tenderness, and 
rigidity of acute peritonitis. Later, when this effusion becomes puru- 
lent, a distinct fixed tumor is formed and is accompanied by character- 
istic inflammatory symptoms. 



ABDOMINAL TUMORS 493 

Midline intraperitoneal swellings are from the left lobe of the liver, 
the stomach, the transverse colon, the mesentery, the omentum, the 
uterus, and the urinary bladder. 

Tumors from the liver exhibit the freest respiratory movement. If 
inflammatory, the local and constitutional signs of this condition are 
commonly present. Gumma must be distinguished by the history 
and the therapeutic test. Cancer is a late manifestation of involve- 
ment elsewhere. 

Tumors of the stomach, in the absence of adhesions, give a respiratory 
excursion and are freely movable, and if of the anterior wall or greater 
curvature, are made more pronounced by inflation. The nature of 
the tumor must be determined by other symptoms, since by palpation 
the distinction between chronic indurated ulcer and carcinoma cannot 
be framed, nor by the sense of touch can an infiltration of the posterior 
wall be distinguished from pancreatic involvement when, as is common, 
adhesions have formed. 

Palpable tumors of the pylorus, usually neoplastic, sometimes inflam- 
matory, are usually found slightly to the right of the midline, and between 
the ensiform process and the umbilicus. They are freely movable, 
particularly toward the left, exhibit respiratory excursion, and are 
pushed downward and to the right on inflation. 

Abscess resulting from the slow perforation of a gastric ulcer is char- 
acterized by inflammatory symptoms rather than those of tumor, except 
when it involves the abdominal wall in front. 

Gumma and benign tumors of the stomach are rare. 

Midline swelling of the colon (rare), usually malignant, is character- 
ized by free mobility and superficial position. 

Omental swellings may present in the midline or well to either side. 
They are characterized by their superficial position and the readiness 
with which they contract adhesions to the parietal peritoneum. 

Hematoma of the omentum, usually postoperative or traumatic, 
exceptionally spontaneous, exhibits a tumor of rapid (hours) develop- 
ment, superficial to the intestines, and attended with the symptoms of 
a mild local peritonitis. 

Torsion of the omentum is characterized by the formation of a tumor 
(hours or days), with the symptoms of a diffuse peritonitis, giving, 
however, less primal shock, and exhibiting much slower progress than 
peritonitis of the perforative type. 

Diffuse tuberculous peritonitis, except that of the serous type, is 
usually characterized by an enormously thickened adherent omentum 
which in its conformation and consistency may closely simulate an 
enlarged and displaced kidney or spleen. Other characteristic symp- 
toms of tuberculous involvement are usually present. 

The omental seat of cysts and tumors might be suggested by the 
demonstrable fact that they lie superficial to the intestines. Diagnosis 
should be made by operation. 

Mesenteric cysts, generally chylous, may lie in the midline or at 
a considerable distance from it. They are usually freely movable, 



494 THE ABDOMEN 

rounded in shape, are of sufficient consistency to suggest a displaced 
spleen or kidney, and are diagnosticated at operation. 

Swellings of the bladder may lie either in the midline or to one side 
of it. Either by percussion or palpation, usually both, the swelling 
can be traced into the pelvis. The common cause for such swelling 
is overdistention, a symptom of which is constant dribbling. Com- 
bined rectal and suprapubic palpation will establish the diagnosis, or, 
if this be unconvincing, the passage of a catheter. 

Tumors of the bladder, usually malignant when large and involving 
its upper portion, are often felt by suprapubic palpation. 

Urachus cysts and abscess of the space of Retzius form extra peri- 
toneal midline tumor which may be difficult to distinguish from those 
lying within the peritoneum. 

Abscess of the space of Retzius, usually secondary to prostatic 
infection, causes a hard, tender swelling behind the pubic symphysis, 
which in its development may extend as high as the umbilicus; it is 
attended with the constitutional symptoms of suppuration. 

Abscess of Douglas' cul-de-sac, when it reaches large size, is prone 
to form a midline suprapubic swelling. The symptoms of local peri- 
tonitis and the results of combined rectal and suprapubic palpation 
establish the diagnosis. 

The womb, if enlarged from pregnancy or pathological cause, exhibits 
a midline swelling which can be traced into the pelvis and the seat of 
which is determined by bimanual palpation. 

Swellings of the Right Upper Quadrant of the Abdomen. — ^These are 
usually of the liver, gall-bladder, renal, or suprarenal origin. 

The acute inflammatory swellings are distinguished from the hyper- 
plastic retention or neoplastic enlargements by local tenderness and 
rigidity and the constitutional symptoms of acute infection. In chronic 
infections the diagnosis must often be made on the basis of the history 
or by exploratory operation. The swellings of the liver can be felt to 
be continuous with this organ and exhibit its respiratory motion. 

Floating liver, usually observed in women and associated with pro- 
nounced visceral proptosis, is recognized by the normal conformation 
and size of the organ and its free mobility and the ease with which it 
can be pushed into its normal position. 

The enlargement of hypertrophic cirrhosis or amyloid degeneration, 
or of Banti's disease, is diffuse, symmetrical, and freely movable, and 
associated with other characteristic symptoms of these conditions. 

The enlargement incident to syphilis may be fixed and exceedingly 
painful and tender. 

RiedeVs lobe, usually observed in women, and often in connection 
with stone in the gall-bladder, forms a tongue-like projection down- 
ward which cannot be distinguished from tumor by palpation, except 
for its smooth, non-nodular surface. In itself it causes no symptoms. 
Corset liver forms a smooth, painless, superficially placed tumor, exhibit- 
ing the respiratory movements of the liver, and usually showing an 
obvious connection with this organ. It does not present in the flank. 



ABDOMINAL TUMORS 495 

Subphrenic abscess of the right side, usually secondary to appen- 
dicitis or to suppuration of the liver or gall-bladder, or of the perirenal 
space, may form a demonstrable tumor by pushing the liver down- 
ward, and by extending upward, causing a dome of percussion dulness, 
or, if the abscess contains gas, one of hyperresonance. Constitutional 
symptoms of acute or chronic infection are present, usually severe 
local pain and tenderness, and often a complicating serous or purulent 
pleuritis. 

Given the history of an abdominal infection no longer active, the 
continuance of sepsis not otherwise to be accounted for, local pain and 
tenderness, and an increase in the area of liver dulness, the diagnosis 
should be made by exploratory incision. 

Liver Abscess. — The tender, swollen liver of acute cholangitis or 
multiple abscess is a minor symptom as compared with the constitutional 
symptoms of profound sepsis. Single abscess, usually placed near the 
upper surface of the right lobe, is rarely recognized as a tumor until 
parietal adhesions have formed when tenderness, edema, and later 
fluctuation, combined with pressure symptoms or chronic sepsis, call 
for incision and drainage. 

Echinococcus cyst, having by preference the liver as its seat of lodge- 
ment, when it becomes large enough to be palpable, forms a smooth 
rounded tumor which may give fluctuation or may seem solid. It is 
of slow growth (months, years), and in the absence of inflammation or 
pressure upon bile ducts or large bloodvessels, causes no symptoms. 
When it suppurates the symptoms are those of abscess. The hydatid 
tremor is neither commonly present nor is it diagnostic when found. 
The absolute diagnosis should be made by exploratory. operation. 

Other cysts present the symptomatology of echinococcus cyst nor can 
the differential diagnosis be made without operation and often micro- 
scopic examination. 

Carcinoma of the liver forms a tumor or tumors characterized by 
dense nodular surface, usually secondary to malignant growth else- 
where, particularly of the alimentary tract, and of the breast, multiple, 
and accompanied by profound cachexia. 

Primary carcinoma (rare) of the liver, when it forms a palpable 
tumor, can be recognized as such only by the careful exclusion of 
syphilis and of the existence of a primary focus elsewhere. Its diag- 
nosis is of importance, since it is amenable to surgical operation. 

Ascites and jaundice develop only if the neoplasm in its growth causes 
pressure upon the portal vein or on the bile ducts. 

Gumma of the liver forms a dense nodular tumor or tumors, which 
by palpation cannot be distinguished from carcinoma. Jaundice or 
ascites may develop as a result of pressure or cicatricial contraction. 
The diagnosis is based upon the history of syphilis and the therapeutic 
test. As a result of syphilitic infiltration, lobulation may occur result- 
ing in a movable mass which may closely simulate floating kidney 
except for its shape and its loose, but obvious, connection with the 
liver. 



496 THE ABDOMEN 

Tumors of the gall-bladder are felt just below the costal arch at 
the point crossed by a line drawn in the male from the nipple to the 
umbilicus. They are characterized, in the absence of adhesions, by free 
mobility, participation in the respiratory movements of the liver, and 
percussion dulness continuous with the organ. Colonic inflation pushes 
them upward, stomach inflation to the right. Except when they reach 
great size, they are neither palpable nor rendered markedly more 
obvious by pressure of an examining hand in the costovertebral angle. 
In distinguishing such tumors from those originating in the kidney or 
the suprarenal body this failure to feel the mass by each examining 
hand in bimanual palpation is the most characteristic feature. Colonic 
inflation will demonstrate the postperitoneal position of small renal 
tumors. 

The gall-bladder tumor, incident to overdistention from blocking of the 
cystic (hydrops) or common duct, if palpable, forms a smooth pyriform 
tumor, usually preceded by a history of colic in the former case, always 
accompanied by signs of jaundice in the latter. 

The tumor of acute cholecystitis is usually masked by the accompany- 
ing tenderness and rigidity. 

The tumor of malignant disease is usually preceded by a history of 
gallstone colic. If palpable, it forms a nodular mass in the gall-bladder 
region, and should be diagnosticated in the absence of disseminated lesions 
by exploratory operation. A palpable tumor is rarely found as a result 
of the chronic cystitis of cholelithiasis, except as the result of omental 
adhesions. 

Renal or suprarenal tumors may be palpated in the right upper 
abdominal quadrant, but usually present in the loin between the costal 
border and iliac crest. They are made more obvious in front by deep 
pressure in the costovertebral angle, exhibit a respiratory excursion less 
free than that characteristic of the swellings of the liver, and; until they 
have reached great size, can be demonstrated as postcolonic by inflation 
of the colon. Moreover, the pain and tenderness of renal swelling, if 
these be present, are referred to the costovertebral angle and to a point 
on the anterior belly wall directly in front of this, and the pain radiates 
downward to the bladder, external genitals, and thighs. 

The swelling of acute infections is masked by the local tenderness and 
rigidity of inflammation, tumor rarely being detected until the perinephric 
tissues are involved. The urinary findings in pyelonephritis are usually 
more characteristic than is swelling. 

Movable or floating kidney is characterized by the renal conformation 
of the freely movable tumor, ability to press it into its normal position, 
accessibility to lumbar palpation, recurrence of the displacement on deep 
breathing or coughing, and a good x-raj picture. 

Hydronephrosis, in addition to forming a distinctly lumbar tumor, 
and being preceded by recurring attacks of renal colic, commonly exhibits 
fluctuation, and while still small can be shown to be postcolic. Marked 
alterations in size are characteristic of intermittent hydronephrosis. 

Neoplasms of the kidney, if sufficiently large to form palpable swell- 



ABDOMINAL TUMORS 497 

ings, are usually malignant; sarcoma in children, hypernephroma or 
sarcoma in adults. The diagnosis is based upon rapid growth, lumbar 
projection, postperitoneal position, and blood in the urine. 

Polycystic disease is characterized by bilateral nodular renal tumor 
and the urinary findings of chronic interstitial nephritis. 

Tumors of the suprarenal bodies (rare) are not palpable until they reach 
large size; their diagnosis as such is dependent upon their position, the 
absence of blood in the urine, and, possibly, displacement of the kidney. 
Orbital metastases are noted in sarcoma. 

Swellings of the Right Lower Abdominal Quadrant. — ^These may be 
retroperitoneal or intraperitoneal. If movable kidney be excepted they 
are fixed, are deeply placed, and are obscured by colonic inflation. 

Congenitally misplaced kidney forms a tumor which may be fixed in 
its abnormal position. Its nature may be suspected from its shape. 

Movable kidney is recognized by its shape and freedom of excursion, 
particularly in the direction of its normal site. The rr-rays will be 
useful in demonstrating the absence of the kidney from its normal 
position. 

Aneurysm of the external iliac artery will exhibit the characteristic 
features of this affection (see p. 99). 

Glandular enlargement, usually malignant and secondary, if large 
enough to be palpable, is suggested by the presence of a constitutional 
cause or a primary focus and a nodular mass occupying the position of 
the lymphatic chain. 

Iliac Abscess. — ^Tuberculosis of the sacro-iliac articulation or of the 
OS innominatum may cause first an infiltration, later an abscess beneath 
and into the iliacus muscle. This may be felt by palpation. The abscess 
usually opens externally before fluctuation can be felt through the 
abdominal walls. The a;-rays are helpful in framing a diagnosis. 

Psoas abscess forms a palpable fluctuating tumor in the right lower 
abdominal quadrant usually long before it presents in the inguinal 
region below Poupart's ligament. The symptoms of spinal caries are 
usually pronounced. 

Perinephric abscess points in the right lower quadrant. The tender- 
ness and induration may be followed into the renal region. 

Malignant growth from the pelvic bones or deep muscles forms a 
rapidly growing fixed tumor which pushes the viscera aside and which 
bimanual examination shows is not attached to the pelvic organs. 

Intraperitoneal Swellings of the Right Lower Quadrant. — These are 
usually due to inflammation of the appendix, to cecal carcinoma, or to 
tuberculosis of the ileocecal region. Rare causes of swelling are abscess 
secondary to gastric or duodenal perforation and actinomycosis. 

The tumor of appendicitis is usually due to omental adhesion and 
thickening, or to abscess formation. In acute cases tenderness and 
rigidity obscure the tumor and are the dominant symptoms. 

The tumor of acute cases which have gone on to abscess formation 
is usually fixed and extremely tender. If the parietal peritoneum be 
uninvolved and the abscess be limited by intestinal coils, tumor with 
32 



498 THE ABDOMEN 

slight tenderness may be the only symptom, the diagnosis here depend- 
ing upon the seat of the tumor and its fairly rapid (days, weeks) develop- 
ment, following an attack of acute appendicitis. In the absence of such 
a history, or with an inflamed appendix lying wide of its normal position, 
the diagnosis would have to be made by operation. 

Chronic abscess or inflammatory thickening may form a mass in the 
right iliac fossa of slow growth (months) and ultimately large size, which 
may so closely simulate malignant infiltration as to require operation 
for a differential diagnosis. Fever is more likely to be marked in the 
inflammatory affection, the onset is usually acutely inflammatory, there 
is a pronounced polymorphonuclear leukocytosis, and the tumor is less 
sharply defined than is the case with cancer. 

Malignant growth of the appendix rarely forms a palpable tumor. 
The distinction from chronic appendicitis should be made by opera- 
tion. 

Tuberculosis of the cecum forms a right iliac intra-abdominal tumor, 
movable or fixed, of slow growth (years), presenting inflammatory symp- 
toms of moderate severity, and attacking by preference children and 
young adults. The hyperplastic form extends along the ascending colon, 
forming a sausage-shaped tumor without mucous membrane ulceration, 
hence there is no blood in the stools. The ulcerative form, usually 
secondary, is attended with parietal involvement and fistula formation. 
The diagnosis from carcinoma, at a time when this is serviceable, can be 
made only by operation, though the age incidence and slow progression 
are suggestive features. 

Carcinoma of the cecum forms a right iliac tumor, movable or fixed, 
hard and nodular, of slow growth (months), affecting by preference the 
middle aged or elderly, usually attended with ulceration of the mucosa, 
hence giving blood in the stools. The diagnosis from chronic appendi- 
citis and tuberculosis should be made by incision. 

Actinomycosis (rare) forms a right iliac tumor of slow growth (months), 
which involves the parietes, opens through blind fistulse, and is distin- 
guished from the ulceration found in tuberculosis only by microscopic 
examination of the discharge. 

Swellings of the Left Lower Abdominal Quadrant. — ^If tumors of the retro- 
peritoneal structure, including subacute or chronic abscess, glandular 
enlargements, aneurysm, and displaced or enlarged kidney, be excepted; 
likewise those tumors incident to pathological conditions of the uterus, 
tubes, and ovaries of women, or the bladder in either sex, swellings of 
the left lower abdominal quadrant are usually due to acute intus- 
susception in children, cancer or acute or chronic diverticulitis of the 
sigmoid in the middle aged or elderly, either of these conditions or 
fecal impaction in the feeble and aged. 

Intussusception is marked by a mass which is movable, often freely 
so, and may palpably vary in size as a result of peristaltic contractions, 
is sausage-shaped and attended with acute or subacute symptoms of 
intestinal obstruction, often together with rectal tenesmus and the 
passage of bloody mucus. 



ABDOMINAL TUMORS 499 

Cancer may be unsuspected until a tumor is felt. This is likely to be 
nodular, irregularly rounded in shape, and more superficial and movable 
than a retroperitoneal growth. Usually detection of the tumor is preceded 
by persistent deep-seated pain with colicky exacerbations and the other 
symptoms of progressive chronic intestinal obstruction. There is likely 
to be occult or obvious blood in the stools. 

The distinction from chronic diverticulitis, with narrowing of the lumen 
of the gut, might be suggested by the absence of occult or obvious blood 
in the stools in the latter condition, the greater tenderness, the more 
marked blood changes of infection, and the younger age incidence. 
Usually the differential diagnosis must be an operative one, at times a 
microscopic one. 

Fecal impaction occurring in the sigmoid forms a mouldable, freely 
movable tumor, the diagnosis of which must often depend upon the 
patient and skilful use of laxatives and high enemata. Occult or even 
obvious blood in the stools may be present as the result of mechanical 
erosion. Such a fecal accumulation may be the result of intestinal 
angulation, volvulus, or stenosis from inflammation or neoplasm. 

Intra-abdominal Swellings of the Left Upper Quadrant. — ^These usually 
originate in the kidney or suprarenal body, in which case they present 
in the loin or in the spleen. In the latter case they are made more 
obvious by colonic inflation, thus differing from renal tumor. 

Floating spleen may have a range of motion so great as to admit of 
its presence in any part of the abdomen. It is usually found in the left 
upper quadrant, or at least can be more readily moved in this direction 
than in any other, and its position is recognized by its shape, the notch 
being characteristic. 

The general symmetrical enlargemerit of the spleen incident to malaria, 
typhoid, miliary tuberculosis, Banti's disease, leukemia, and pseudo- 
leukemia is attended with other characteristic symptoms. 

Abscess of the spleen may be so latent as to defy diagnostic efforts. 
Enlargement of the spleen occurring in the course of rheumatic fever, 
typhoid, malaria, or other infectious process, characterized in its further 
development by chills, fever, sweat, and the blood changes of suppura- 
tion, and particularly by pain, tenderness, and fixation of the diaphragm 
and the development of slight basal pleurisy, should suggest splenic 
abscess. 

Echinococcus cyst forms a round, usually fluctuating tumor of slow 
growth (years) and not prone to contract adhesions until suppuration 
develops. The constitutional symptoms of other forms of splenic 
enlargement are absent. Hydronephrosis may be eliminated by colonic 
inflation, examination of the urine, and catheterization of the ureters. 

Sarcoma of the spleen is characterized by comparatively rapid (months), 
somewhat nodular, painful growth of the organ and the elimination of 
constitutional conditions which attend other forms of enlargement. 

Subphrenic abscess to the left of the suspensory ligament of the liver 
is usually due to perforation of the stomach, pancreatitis, splenic abscess, 
perinephric suppuration, perforating empyema, or necrosis of the verte- 



500 THE ABDOMEN 

brae or ribs. Depending on the primal cause, the onset will be stormy 
or insidious. In its developed form the diaphragm is displaced upward 
and fixed. The spleen and stomach are pushed down. The symptoms 
are similar to subphrenic suppuration of the right side. 

Tumors, when they are not observed until they reach large size, may 
so fill the abdominal cavity that their point of origin may be dijQScult to 
determine except by operation. 

Certain acute conditions are attended with tumor formation which may 
vary in its location. The rapid distention of the sigmoid incident to 
volvulus may force this loop of gut, normally pelvic in position, as high 
as the lower border of the stomach. Internal strangulation or incar- 
ceration by twist or band, depending on its seat, may be characterized 
by the rapid development of a resonant tumor in any part of the belly. 
The same may be said of acute obstruction incident to enteroliths, foreign 
bodies, masses of round-worms, large gallstones which have ulcerated 
into the gut, malignant growths of the small intestine, hematoma, torsion 
or infection of the omentum, disseminated carcinoma or tuberculosis 
of the peritoneum. The abscess due to appendicitis may be wide of 
its usual seat. 

HERNIA. 

Hernia, as the term is generally used, implies the protrusion of an 
abdominal organ through a parietal opening. The affection is com- 
monest in infancy, old age, and puberty. 

The usual predisposing causes are congenital malformation, a flabby 
musculature, and looseness of cellular tissue, often incident to emacia- 
tion. The pull of a subserous lipoma, the recurring push of a chronic 
cough, repeated straining incident to obstructed urination or defecation, 
the intra-abdominal pressure of violent muscular effort, trauma — these 
are the common exciting causes. 

Diagnostic symptoms of hernia are: The presence of a tumor, usually 
in a hernial region, or in one weakened by traumatism, generally of 
gradual formation (weeks, months), at times developed suddenly, 
unattended with inflammatory symptoms, varying in size and consistency 
in accordance with the position of the patient and changes in intra- 
abdominal tension, giving expansile impulse on coughing, usually 
resonant on percussion, reducible, often with a gurgling sound, and 
readily retained by moderate pressure over its orifice of escape. The 
examining finger can be pushed deeply into this orifice. 

An omental hernia will exhibit neither resonance on percussion nor 
gurgling on manipulation and reduction, and, if irreducible, may not 
obviously change in size or conformation with changes in the patient's 
position, nor give an expansile impulse on coughing. The neck of such 
a tumor can, however, usually be traced through the hernial orifice 
and canal into the interior of the abdomen, and there can be obtained 
a history of its gradual development and of its repeated spontaneous 
or manual reduction in its early course. 



HERNIA 501 

Internal hernise Into the jejunoduodenal, pericecal, and sigmoid 
fossae, or through the foramen of Winslow, can be diagnosticated only by 
operation called for by the complication of incarceration or strangulation. 

The external hernlse are readily recognized if present at the time of 
examination, except in the case of small protrusions occurring in fat 
people. The patient may, however, give a history quite typical of hernia, 
yet fail to exhibit the lesion. Enlargement of the ring usually can be 
demonstrated. Protrusion may be accomplished by violent coughing, by 
lifting a heavy weight with the knees straight and the back bent for- 
ward, or by seating the patient on the edge of a chair with flexed knees 
and the legs moderately separated and directing him to make straining 
efforts as in defecation. 

The bulging of the abdominal wall over Poupart's ligament Is a 
natural conformation in many men, nor is Impulse against the finger 
passed through the patulous external ring of absolutely diagnostic 
moment, in so far as the presence of a hernia which Is likely to be pro- 
gressive is concerned. 

A hernia Is termed irreducible when it remains permanently in Its sac. 
This is usually due to adhesions between the hernia and the sac wall. 

Incarcerated hernia is one In which there is obstruction to the onward 
passage of the intestinal contents from massing of feces incident to 
angulation or sharp flexion of the gut, or the pressure of the hernial 
ring. The circulation of the involved bowel loops is not obstructed. 
The symptoms are those of an irreducible hernia larger than usual 
and accompanied by colicky pain, active peristalsis, vomiting, and con- 
stipation, with remissions or intermissions and exacerbation. There 
may be local tenderness, but inflammatory symptoms are absent. 

A strangulated hernia is one in which there is blood stasis from con- 
striction. This constriction, which may lie in the ring or in the sac 
at its neck, may become suddenly operative by an added loop of gut 
or portion of omentum being suddenly thrust through It. 

Strangulation is attended at times with shock, usually by severe pain 
exhibiting paroxysmal exacerbations, vomiting, constipation, and, follow- 
ing this, the hyperperistalsis of acute obstruction. The hernia itself is 
painful, tender, and swollen. There is no impulse on coughing, and a 
preceding resonance may be exchanged for percussion dulness incident 
to effusion Into the sac. 

Strangulation occurring in long-standing irreducible hernise, par- 
ticularly those of the aged, may be marked at first by no symptoms 
other than colicky pains, moderate vomiting, constipation, and a slight 
increase in tenderness. In these cases the rapid development of pro- 
found toxemia may be the most conspicuous symptom. Under such 
circumstances, when there is a double hernia, a not unusual condition 
in the aged, the determination as to which one is responsible for symp- 
toms may be impossible without operation. 

When strangulation Is due to bands or adhesions within the sac, the 
reduction of the hernia will not be followed by relief of symptoms. 

The severe abdominal pain of uremia, with vomiting and consti- 



502 THE ABDOMEN 

pation, if associated with hernia, may cause error in treatment, nor is 
an examination of urine helpful, except in that it may show chronic 
nephritis. If, with such symptoms, local tenderness and increased size 
were present in an irreducible hernia, the diagnosis would have to be 
made by operation. 

The distinction between strangulation and incarceration, or simple 
inflammation, when this is not clear, should be made by timely opera- 
tion. 

Inguinal Hernia. — This, the commonest form of hernia, may be in- 
complete or complete, congenital or acquired, and is most frequent in 
males. 

Fig. 336 




Large bilateral inguinoscrotal hernia. Incompletely reducible; penis concealed by downward 
dislocation of skin. Preputial orifice at middle of swelling. All characteristic signs of hernia 
present. (Carnett.) 

Indirect, or oblique, inguinal hernia passes primarily through the 
internal ring, with the deep epigastric artery necessarily internal to 
the neck of its sac. It usually contains the ileum and omentum, not 
infrequently the cecum or appendix, or both, on the right side, or 
the colon on the left side, in which cases the sac may be incomplete 
(sHding hernia). 

At times, especially in hernise which have recurred after radical 
cure, the bladder forms a part of the hernial projection, usually with- 
out a peritoneal investure, and may be wounded during operation. Its 
presence is suggested by a mass of fat pulled into the wound at its 
lower angle. 



HERNIA 



503 



When a considerable portion of the bladder is included in the hernia 
and the portion communicates freely with the rest of the bladder cavity, 
there will be a diminution in the size of the tumor after urination; 
or, if this is not the case, after having urinated, and having emptied 
the sac by manipulation, a further considerable quantity of urine can 
be passed. 

There is usually an associated cystitis, and the hernia can be made 
more prominent by filling the bladder w^ith an injection. 

The indirect or oblique hernia is usually dependent for its develop- 
ment upon a persistent patulous condition of the peritoneal pouch which 
accompanies the testicle in its descent. \Vhen this pouch remains 
completely open, and the hernial contents pass down to the testicle, 
the hernia is called congenital. ^Vhen the pouch is closed just above 



Fig. 337 




Oblique inguinal hernia, showing fulness along inguinal canal and at external ring, but not 
extending into the scrotum. 



the testicle, the hernia descending w4th the cord, it is called funicular. 
When the pouch remains open excepting at the internal ring, either 
an infantile or encysted hernia may develop. In the former case a 
sac forms behind the patulous funicular process; in the latter, a sac 
becomes invaginated into its lumen. 

The hernial sac incident to a patulous condition of the vaginal tunic 
not infrequently exhibits constrictions, valve-like folds, and diverticula, 
which may be even larger than the direct sac. These diverticula may 
pass between any of the abdominal layers, and may mislead the surgeon 
into the belief that he has accomplished a reduction of the hernia when 



504 THE ABDOMEN 

in reality he has pressed it into a side pocket. The hernia can be made 
to ahernate between its two positions. A properitoneal hernia is one 
which habitually lodges in an intraparietal peritoneal diverticulum. 

Direct, or internal, inguinal hernia passes to the inner side of the 
deep epigastric artery between it and the outer border of the rectus 
muscle. It is always acquired, of slow formation, occurs in elderly 
males, and is due to muscular and fibrous relaxation. 

The sac of the indirect or oblique inguinal hernia passes downward 
and inward, then forward. The direct hernia comes directly forward. 
From long-continued drag, an oblique inguinal hernia may seem 
direct. The position of the deep epigastric artery in relation to the 
sac, if it can be felt, which is exceptional, will establish the distinction. 
The hernise of the young and vigorous are practically always oblique. 
The hernise of the old and debilitated are often direct and bilateral. 

When an inguinal hernia is incomplete, it must be distinguished in 
infants from retained testicle. Absence of this gland from its usual 
position would seem a suggestive feature, but is often overlooked. The 
testicle can be distinctly outlined, and never exhibits an expansile im- 
pulse on coughing. The two conditions of non-descent and hernia are 
often associated. 

Hydrocele of the cord, common in infants, exhibits a high degree of 
translucency and fluctuation. It may traverse the entire length of the 
inguinal canal, and in rare cases may be completely reducible; this 
is accomplished very slowly, nor is there sudden return of the complete 
swelling, as is the case in hernia. It is always dull on percussion and 
does not exhibit expansile impulse on coughing. A slight translucence 
is sometimes observed in the hernise of infants. Cyst of the canal of 
Nuck, occurring in women, rarely offers diagnostic difficulties. 

The distinction between an irreducible omental hernia and a lipoma 
of the cord may be extremely diflScult. The possibility of tracing the 
neck of the hernia into the abdominal cavity through its aperture of 
escape would be suggestive of hernia. Pronounced movement imparted 
by traction upon the testicle would be more characteristic of lipoma of 
the cord. 

Hematocele exhibits the characteristics of hydrocele, except that it 
is less soft and fluctuating and gives no translucence to light. 

Dermoid of the inguinal canal (rare) exhibits a distinct outline, and 
except for its position has none of the characteristics of hernia. 

Postperitoneal abscess commonly points below Poupart's ligament. 
The symptoms of the cause underlying this condition are usually suffi- 
ciently obvious. Unless it be acute or subacute, the swelling can be 
traced to the inguinal fossa and is attached to the deeper structures. 

An inflamed inguinal gland, if complicated by hernia, may occasion 
some diagnostic difficulty, since by its extension it may occasion inflam- 
mation of the sac, deep pain, nausea, vomiting, and constipation. Diag- 
nosis in the presence of obstructive symptoms should be made by 
operation. 



HERNIA 505 

Femoral Hernia. — Femoral hernia, protruding through the femoral 
ring and canal and the saphenous opening, never attains the huge 
size noted in inguinal hernia. It is always acquired, and is commonest 
in adult females. It appears as a globular swelling below the inner 
third of Poupart's ligament, and often turns upward, thus simulating 
inguinal hernia. Its neck lies below Poupart's ligament and external 
to the spine of the pubis, while the neck of an inguinal hernia is above 
Poupart's ligament and internal to the pubic spine. This bony point 
is located by abducting the thigh and following upward the adductor 
longus tendon which is attached just below it. 

The distinction between irreducible femoral epiplocele and lipoma 
may be impossible unless there be given a clear history of the gradual 
formation of a tumor at one time distinctly reducible, or the lipoma 
exhibit its characteristic lobulations, skin adhesions, and free mobility 
on the deeper parts. In case of doubt the diagnosis should be made 
by operation. 

The distinction between femoral hernia and psoas abscess or cold 
abscess from necrosis of the pelvic bones is based in part upon the 
usual seat of the two affections. The hernia lies to the inner side of the 
femoral artery, the abscess points to the outer side. The psoas abscess 
usually can be traced through the abdominal parietes, passing upward 
along the psoas muscle or backward and outward into the iliac fossa, 
and fluctuation can be elicited in it by abdominal pressure. It may 
exhibit both partial reducibility and expansile impulse on coughing. 

Cyst in the region of the femoral hernia, due possibly to obliteration 
of the abdominal opening of a femoral sac, is suggested by fluctuation 
if this can be clearly elicited. It often exhibits the consistency of an 
epiplocele and should be distinguished from the latter condition by 
operation. 

The distinction from inflamed glands is based upon the presence of 
an adequate cause for this condition, the rapid development, induration 
and tenderness, and the early appearance of the skin phenomena of 
inflammation in the absence of any marked gastro-intestinal disturbance. 

Lymphangiectasis or venous varicosities may form a tumor in the 
femoral region markedly influenced in size by position and abdominal 
tension, and in the case of the veins, giving expansile impulse on cough- 
ing. The convolutions of the dilated vessels are usually distinctly 
seen, if not at the seat of maximum swelling, at least below, nor does 
diagnosis present difficulties if the possibility of tumor formation from 
these sources be borne in mind. 

Umbilical Hernia. — Umbilical hernia is a protrusion of one or more 
abdominal structures at the umbilicus. The congenital form is due 
to imperfect union of the two lateral plates of the abdomen at the mid- 
line; the protrusion occurs into the base of the cord, and the contents 
are visible through the amniotic layer which covers them. 

Acquired umbilical hernia occurs either in early infancy or in women 
after their twenty-fifth year. Repeated pregnancy and obesity are 
favoring factors. The upper and weaker part of the navel is the seat 



506 



THE ABDOMEN 



of predilection. The umbilical hernia quickly becomes irreducible, 
attains huge size, and is subject to strangulation. The diagnosis is 
obvious. 



Fig. 338 




Umbilical hernia. 



Type commonly seen in infants. Easily reducible. 
Ring tight to tip of finger. 



Impulse on coughing. 



Ventral Hernia. — ^Ventral hernia may occur through any part of the 
abdominal wall weakened by scar, muscular or fascial rupture, or dias- 
tasis. That form due to separation of the recti muscles is best demon- 
strated by directing the patient to lie on her back and raise her head 
and shoulders from the pillow without the aid of the arms; the hernial 
protrusion can then be seen and the median borders of the recti muscles 
can be felt. 

Lumbar Hernia. — Lumbar hernia, if not due to scar, usually occurs 
through Petit's triangle, a weak space lying between the external 
oblique and latissimus dorsi muscles, slightly behind the summit of the 
iliac crest, or through a vascular opening on the latissimus slightly 
behind this. 

The lumbar region is a favorite seat for both abscess and lipoma. 
The former may be reducible and give impulse on coughing, but 
exhibits characteristic symptoms of the causative lesion. The latter 
is usually lacking in hernial symptoms. 

Sciatic, or Ischiatic, Hernia. — Sciatic, or ischiatic, hernia occurs through 
the greater or lesser sacrosciatic foramen and may be either above or 
below the pyriformis muscle. It may remain under the gluteus maximus 
muscle or protrude beneath its lower border. 

Obturator Hernia. — Obturator hernia (rare) is not likely to be recog- 
nized except when symptoms of strangulation call, as they invariably 
do,, for a careful examination of the hernial orifices. Under such cir- 
cumstances there may be felt a tender tumor in the region of the pecti- 



THE STOMACH AND DUODENUM 507 

neus muscle. As a means of lessening tension, the thigh of the affected 
side will be kept flexed, nor can it be moved without pain. More- 
over, there will probably be pain referred along the course of the obtura- 
tor nerve and disturbance of sensation on the inner surface of the thigh 
and leg. 

The obturator hernia lies below and internal to the position of femoral 
hernia. 

Perineal Hernia. — Perineal hernia protrudes through some part of 
the pelvic floor, usually between the fibers of the levator ani muscle, or 
between it and the coccygeus. It may lie beside the rectum or the 
vagina, bulging into their lumina, or appear in the labium majus, form- 
ing a vulvar hernia. Since the sac invariably contains gut, the tumor 
is readily reducible, and exhibits practically all of the characteristic 
hernial features; a diagnostic failure is scarcely possible if the existence 
of hernia in this region be recognized. 

Littre's Hernia. — ^This is one made up of a Meckel's diverticulum. 

Richter's Hernia. — This is one in which only a portion of the circum- 
ference of a knuckle of intestine is involved. 

Strangulation of either of these two hernise should give mild symp- 
toms. The diagnosis should be made by operation. 

Internal HernisB. — The duodenojejunal, pericecal, intersigmoid, and 
foramen of Winslow hernise can be diagnosticated as such only when, 
because of symptoms of internal strangulation, operation is required. 

Diaphragmatic hernia, usually following a wound of the diaphragm, 
either immediately or long after, is characterized by the acute onset of 
dyspnea, shock, and the symptoms of intense strangulation, with the 
tympany of an abdominal organ elicited by chest examination, and 
displacement of the left lung and the heart. If of gradual formation 
incident to congenital malformation, intestinal gurgling heard on chest 
auscultation may suggest the diagnosis. Displacement of the heart to 
the right in the absence of pleural effusion is suggestive. Diagnosis is 
usually not made until the symptoms of internal strangulation call for 
operation. 

THE STOMACH AND DUODENUM. 

From the subdiaphragmatic portion of the esophagus the empty 
stomach hangs as a flaccid sac, the long axis of which, at first vertical, 
Swings forward and to the right until the pylorus is reached. 

When distended, the stomach assumes a pyriform shape, the larger 
expansion, or fundus, extending to the left and rising posteriorly one to 
two and one-half inches above the level of the cardia, thus lying behind 
the apex of the heart. The greater curvature of the full stomach is 
usually one or two inches above the level of the umbilicus. 

The cardia, which is the most fixed part of the stomach, is placed at 
a depth of about five inches, directly behind the sternal articulation of 
the left seventh costal cartilage. The extremely movable pylorus lies, 
when the stomach is empty, an inch below and the same distance to 



508 THE ABDOMEN 

the right of the tip of the ensiform cartilage, on a level with the body 
of the eleventh or twelfth dorsal vertebra. 

The capacity of the stomach at birth is from 20 to 30 c.c. This rapidly 
increases until at the end of the third month it is about 100 c.c. There- 
after, for a period of three months, there is very little increase in size. 
Then follows a capacity development commensurate with the general 
body growth. The adult stomach holds from 1500 to 2000 c.c, but 
these figures by no means represent the extremes of normal variation. 
Moreover, the position of this organ and the direction of its long axis 
may depart greatly from that just given, without other signs or symp- 
toms of impaired function. 

The larger bulk of the stomach, lying to the left of a line dropped 
in the long axis of the body from the right side of the cardiac orifice, 
and including the fundus, the body, and a large part of the greater 
curvature nearly to the antrum pylori, is mainly a secreting reservoir 
and a mixing chamber for the conversion of food into chyme. Its few 
collecting lymph glands communicate with the splenic group. It is this 
portion of the stomach which is principally affected by dilatation. 

The thicker and more muscular pyloric end of the stomach lies to the 
right of the vertical line just given, and is not only a secreting but an 
actively moving part which accomplishes the thorough mixing of the food 
with the gastric juices and propels this when it is properly prepared 
through the pylorus into the duodenum. Collecting lymph glands are 
abundant about this portion of the stomach, particularly along its 
lesser curvature, the direction of the lymph flow, even from the lower 
border of the antrum, being toward this group. 

This portion of the stomach is mainly affected hy ulcer and cancer and 
perigastric adhesions. 

The stomach is essentially a secreting and not an absorbing organ. 
Its secretion, hydrochloric acid, propepsin, and lab ferment, is actively 
excited by psychical influences, but is in the main under the direct 
control of its essential ganglia. This is also true of its movements. Its 
function is that of proteid digestion, particularly of connective tissue, 
thus facilitating the later action of the pancreatic secretion upon the 
fats and muscle cells. Its secretion has a distinctly antiseptic action 
upon food. 

The cardia is a physiologically incompetent valve in infancy. In 
adults it is occasionally subject to spasm. It admits from the stomach 
side three fingers to the first joint. The pylorus, occasionally subject 
to spasm and hypertrophy in infancy, a frequent seat of ulceration in the 
adult, should normally admit the index finger past the first joint. It has 
a free range of motion, and, unless distinctly indurated, is not palpable. 

The normal stomach should have disposed of an ordinary full meal in 
six hours, vomiting efforts or expressage showing no remains of such a 
meal after this interval. The test breakfast of tea and toast is often 
passed from the stomach in one hour. Persistent delay in transmission 
indicates either a deficient propulsive power or obstruction, usually the 
latter. 



THE STOMACH AND DUODENUM 509 

The cardinal symptoms of surgical affections of the stomach are 
pain, evidences of pyloric obstruction, hemorrhage, and tumor. 

Pain, which in its time of onset and maximum severity bears a relation 
to food ingestion, which is sharply localized and which is relieved by 
vomiting, is a symptom to which great importance is justly attached, 
particularly when it is associated with an area of tenderness to deep 
palpation, and, exceptionally, with a sharply localized area of parietal 
hyperalgesia. 

Hemorrhage, as shown by examination of the vomitus, or of the matter 
expressed from the stomach, or of the stools, is of diagnostic value in 
accordance with its severity, recurrence, persistence, and its association 
with other symptoms. 

Pyloric obstruction is characterized by delay in the passage of the 
stomach contents, hypertrophy, visible peristalsis in thin persons, 
gurgling sounds, eructations and postprandial discomfort, and, in the 
late stages, gastric dilatation and vomiting of food taken many hours 
before, and exceptionally tetany. 

Either absence or excess of hydrochloric acid or of the digestive 
ferments constitutes a corroborative rather than a pathognomonic sign 
of surgical disease. The bacteria and ferments of decomposition are 
indicative of obstruction, and depend upon its degree rather than upon 
its nature. 

Tumor, a late manifestation of gastric disease if congenital hyper- 
trophic stenosis be excepted, is usually perceptible to palpation only 
when it involves the pylorus or the anterior stomach wall. Extensive 
infiltration of the posterior wall can be felt when the stomach is not 
distended. 

The duodenum, the thickest-walled, widest, and most vascular part of 
the small intestine, ten to twelve inches long, and forming in its course 
a V or U, within the angle or concavity of which lies the head of the 
pancreas, is movable and provided with a complete peritoneal invest- 
ment only for the first two inches of its course. The direction of this 
movable part is transverse, with an upward and backward tilt, its distal 
end forming the lower border of the foramen of Winslow, while behind it 
lie the common bile duct, the hepatic artery, and the portal vein. Below 
is placed the head of the pancreas. 

The rest of the duodenum is covered with peritoneum only in front. 
The descending portion, about three inches in length, lies to the right 
of the head of the pancreas, with the common bile duct passing behind it 
and entering 1.4 inches below a crescentic fold of mucous membrane 
placed at the junction of the first and second parts of the duodenum on 
the posterior aspect. At the point of entrance there is a papilla which 
caps the ampulla of Vater, a space lying within the wall of the bowel 
and receiving both the biliary and the pancreatic duct. These ducts 
may enter by separate orifices. The accessory pancreatic duct (duct of 
Wirsung) enters the duodenum above the papilla. 

The longest portion of the duodenum, the third, or transverse (five 
inches), passes below the pancreas across the great vessels from right to 



510 THE ABDOMEN 

left and slightly upward, behind the superior mesenteric vessels and 
the root of the mesentery. The ascending fourth part lies almost as 
high as the beginning of the duodenum, on a level with the first or 
second lumbar vertebra, and is sharply angled forward at its continua- 
tion with the jejunum, being held in position by a musculofibrous band 
— the ligament of Trietz — which, in conjunction with the peritoneal fold 
passing from the duodenum to the right parietal peritoneum, forms the 
duodenojejunal fossa, into which retroperitoneal hernia may occur. 

As is the case with the stomach, the duodenum is essentially a secre- 
ting and not an absorbing organ. Under the stimulating effect of the 
acid chyme of the stomach it forms a product, secretin, which not only 
excites its own cellular activity but stirs the liver and pancreas to hyper- 
secretion. The duodenal secretion also contains invertin which splits 
cane sugar, lactase which acts on lactose and, of major importance, 
enterokinase which converts the trypsinogen into trypsin, thus activating 
the pancreatic secretion. 

Just below the entrance of the bile and pancreatic ducts there has been 
described a sphincteric arrangement of fibers (Ochsner), the presence 
of which there is clinical evidence to support. The invariable or usual 
presence of such a sphincter, however, has not been confirmed anatom- 
ically (Boothby). 

The crossing of the superior mesenteric vessels and root of the mesen- 
tery over the third, or transverse, portion of the duodenum has been con- 
sidered the etiological basis of some cases of acute gastric dilatation. 

The lymphatic glands of the duodenum, few in number, lie along its 
inner angle or curve, their vessels passing to the glands along the lesser 
curvature of the stomach. 

The symptoms of surgical affections of the duodenum are pain, tender- 
ness, hemorrhage, obstruction to the onward passage of chyme from the 
stomach, or bile or pancreatic juice from their secreting glands, and very 
exceptionally, palpable tumors. The pain has a constant and distinct 
relation to gastric function, coming on some time (hours) after eating 
and being temporarily relieved by taking food. The pain and associ- 
ated tenderness on deep palpation are often placed to the left of the tip 
of the ensiform and somewhat below it. The hemorrhage may appear 
only in the stools. 

Trauma of the Stomach.— Contusion. — Contusion is characterized 
by shock, vomiting, sometimes of blood, severe pain . and very often 
localized tenderness and rigidity. There may be free bleeding either 
into the stomach itself or into the peritoneal cavity without actual rup- 
ture of all the gastric coats. 

The diagnosis from rupture is based upon prompt recovery from shock 
and the retrogression of symptoms. 

Rupture of the Stomach. — Rupture of the stomach is usually due to 
external violence, exceptionally in surfeited drunkards to muscular 
action. It is characterized by severe pain, shock, and the rapid devel- 
opment of symptoms of diffuse peritonitis. Initial shock may be 
absent. 



THE STOMACH AND DUODENUM 511 

Diagnosis must be based upon the suddenness of onset, steady progres- 
sion of symptoms, and exploratory operation. 

Wound of the Stomach. — ^Wound of the stomach may be suggested 
by vomiting of blood after traumatism, and the nature of the vulner- 
ating body and the direction taken by it. When this is practicable, the 
following under general or local anesthesia of the track of the wound 
will lead to a correct conclusion. Perforation, excepting in the case 
of modern small caliber weapons of high velocity, is denoted shortly by 
the beginning symptoms of a local or diffuse peritonitis. 

Foreign Bodies in the Stomach. — Foreign bodies in the stomach are 
blocked by the pylorus, this being the narrowest part of the alimentary 
canal. Unless these bodies cause either obstruction or ulceration, they 
may lie for years and cause no symptoms. 

The diagnosis is based upon the history, the use of the rr-rays when 
applicable, and the symptoms of either ulceration or obstruction. 

Acute Dilatation of the Stomach. — ^Acute dilatation may follow surfeit, 
anesthesia (particularly by chloroform), operation (especially on the gall 
passages), traumatism, infection (particularly pneumonia), or systemic 
intoxication. 

It is characterized by a muscular and vasomotor paresis, the former 
allowing of great dilatation, the latter of a copious transudate appearing 
as an offensive but not feculent, thin, brown vomitus. 

As the distended stomach forces the colon and the small intestines 
downward, the drag upon the root of the mesentery and the superior 
mesenteric vessels completely occludes the third part of the duodenum, 
thus adding to the dynamic obstruction a mechanical one. This mechan- 
ical obstruction is regarded by many as the primary cause of the dilata- 
tion. 

Acute dilatation of the stomach begins with sudden acute pain, if post- 
operative usually within the first twenty-four hours, at times not for 
many days. This pain is placed in or about the stomach and is asso- 
ciated with moderate tenderness. The stomach rapidly dilates forming 
a tense resonant swelling most marked at first in the epigastric region, 
later filling and distending the entire belly. The vomiting is recurrent 
and profuse, often effortless. The constitutional symptoms are pro- 
foundly adynamic, the pulse becoming weak and running, the respira- 
tions hurried and shallow, the face gray and pinched. 

The diagnosis is based upon the early epigastric swelling, the character 
of the fluid vomited and its extraordinary quantity, and the beneficial 
effect of gastric lavage and, at times, the Trendelenburg or knee-chest 
position. Stomach splash is said to be characteristic. 

This affection is more rapid in onset than peritonitis, except that of 
the perforative type, is not marked by the characteristic rigidity or 
extreme tenderness of the latter condition, and exhibits promptly the 
symptoms of an overwhelming toxemia rather than those of an inflamma- 
tory reaction. 

The distinction between the paresis and dilatation of both the stomach 
and intestines, characteristic of the terminal stage of postoperative diffuse 



512 THE ABDOMEN 

peritonitis, and acute dilatation of the stomach, in the absence of a 
demonstrable infective cause, may be most difficult. The prognosis of 
this condition when well developed is grave. 

Pyloric Obstruction. — ^Pyloric obstruction may be due to muscular 
hypertrophy or spasm, or both, to gastroptosis, inflammatory or neoplastic 
infiltration, cicatricial contracture, perigastric adhesions, or pressure of 
external tumors. The symptoms of the condition bear but little relation 
to the cause, being incident to the amount of obstruction. 

Hypertrophic stenosis of the pylorus, commonly called pylorospasm, is 
essentially an affection of early life, developing shortly after birth (first 
month). It is occasionally observed in older children, exhibiting a 
tendency to recur. The obstruction is partly due to muscular spasm 
of the hypertrophied pyloric sphincter and partly to redundant folds of 
mucous membrane. 

It is characterized by colicky pain, vomiting, visible peristalsis, the 
presence of a movable nodule about the size of a hazelnut in the pyloric 
region (80 per cent, of cases, Nicoll), great hunger, wasting, and constipa- 
tion. The vomiting is frequent, explosive, occurs shortly after eating, 
and is free from bile, mucus, or blood. In the later stages, when gastric 
dilatation supervenes, several nursings may be retained, followed by 
vomiting in quantity. 

Wasting and persistent vomiting are so common in improperly nourished 
infants that the diagnosis of pylorospasm should not be seriously con- 
sidered until the effect of judicious feeding has been carefully studied. 
The cyclic vomiting, usually accompanied by acetone and diacetic acid in 
the urine, is characterized by its comparatively brief recurring paroxysms, 
with intervals of complete health. The vomiting of Henoch's purpura 
(angioneurotic edema) is characterized by its sudden, violent, painful 
onset — often blood in the vomited matter and the stools and especially 
by purpuric skin spots. Cerebral vomiting is in children usually 
attended with characteristic symptoms of chronic meningitis (tuberculous 
or syphilitic). 

Gastroptosis. — Gastroptosis, usually associated with enteroptosis, right 
nephroptosis, at times with dilatation, is most often found in emaciated and 
hysterical females, and, even though extreme, occasions no symptoms 
unless there be angulation at the pylorus. The pylorus is always dis- 
placed downward or to the left or in both directions, sinking from the 
level of the first lumbar vertebra, its normal position, as low as that of 
the fifth. 

The condition may be incident to congenital pyloric displacement or 
abnormal mobility, colon drag, relaxed gastrohepatic ligament, or press- 
ure on the part of the sagging liver. Above the lesser curvature the 
body of the pancreas may be felt at times where this structure crosses 
the lumbar vertebrae. 

The symptoms of gastroptosis, when these develop, are those of pyloric 
obstruction and ultimate dilatation. The latter may become recurringly 
acute. Physical examination supplemented by the stomach tube and 
inflation usually satisfactorily reveals the condition. The assured diag- 



THE STOMACH AND DUODENUM 513 

nosis is, however, best made by means of the x-rays with the patient in 
a standing position. By this may be demonstrated the size, shape, 
position, and mobihty of the stomach 

Perigastric Adhesions. — Perigastric adhesions, incident to a local peri- 
tonitis, usually caused by gastric ulcer or cholecystitis, symptomless 
except when the region of the pylorus is involved, are characterized by 
pain at times constant, but most marked after eating, exaggerated 
peristalsis, and gastric indigestion; exceptionally by retention of food, 
dilatation, and vomiting. The diagnosis is based upon the elimination 
of non-surgical causes for such a symptomatology, the history of a pre- 
vious local peritonitis, and the fact that the symptoms are stationary or 
at the worst but slowly (years) progressive. 

Volvulus of the Stomach. — ^Volvulus of the stomach, by which is meant 
a twist of the organ on its long axis, an extremely rare accident, is only 
possible in conditions of gastroptosis. It is characterized by pain, 
shocking in intensity, rapid distention of the stomach, and inability to 
vomit or eructate. 

Ulcer of the Stomach. — Ulcer of the stomach may appear as an erosion 
so slight as to escape even postmortem examination, as an abrasion, as 
acute round ulcer, or as an indurated chronic ulcer. 

The acute ulcer^ either of the superficial or deep type, may appear in 
any part of the stomach, particularly on the posterior wall and along the 
lesser curvature. It is common in anemic hysterical young women 
(about twenty-five years old), is probably a local expression of sepsis, and, 
when placed on the anterior wall, is prone to bleed and to perforate. 

The diagnosis of gastric ulcer is based upon hemorrhage, which may 
be occult, slight, profuse, or very exceptionally promptly fatal; pain, often 
localized, markedly aggravated by taking food, and relieved by vomiting 
or stomach lavage or orthoform (Murdoch); tenderness, also frequently 
well localized, hyperperistalsis, and excess of hydrochloric acid in the 
gastric content. 

When the ulcer is placed near the pylorus, and either by its hyperemia, 
induration, or cicatricial contracture causes spasmodic contracture or 
pronounced mechanical narrowing of this orifice, there will be added to 
the symptoms just noted those of pyloric obstruction characterized by 
retention of food, hyperperistalsis, dilatation, absence of hydrochloric 
acid, and lactic fermentation. 

As symptoms of corroborative, but not diagnostic value, anemia, 
emaciation, constipation, and the occasional association with pulmonary 
tuberculosis may be mentioned. 

Referred pain and cutaneous hyperalgesia are at times well marked, the 
seats of preference being over the ensiform cartilage or to one side of it, 
and at a point in line with the scapular angle at the level of the ninth 
dorsal spine (Head). 

The one symptom upon which most reliance can be placed is hemor- 
rhage. This, if profuse and vomited, in the absence of adequate trauma- 
tism, blood dyscrasia, or vascular back pressure, can be regarded as almost 
pathognomonic of ulceration. Constantly recurring slight hemorrhage, 
33 



514 THE ABDOMEN 

shown by the presence of occult blood in the vomited matter or that 
drawn from the stomach by lavage, is considered equally diagnostic 
in the absence of either renal or hepatic disease. 

Abdominal arteriosclerosis may cause acute attaclis of pain, suggesting 
perforation, or may be characterized by recurring paroxysms closely 
simulating those of ulcer or carcinoma, Berger reports cases suffering 
from postprandial pain, emaciation, and bleeding, in which an autopsy 
failed to demonstrate the erosions from which the bleeding came. 

Though in typical cases the symptoms of gastric ulcer are sufficiently 
characteristic to make the diagnosis well-nigh certain even in the absence 
of exploration, the frequency with which the first symptoms, barring 
slight digestive disturbance, are those of acute perforative peritonitis, 
proves that ulcer may exist without offering any symptoms upon which 
even a probable diagnosis can be based. 

From the surgical point of view the diagnosis is important because of 
the complications of hemorrhage, pyloric obstruction, diffuse perforative 
peritonitis, localized peritonitis with gradual extension of inflammation, 
perigastric adhesions, or pus formation. These conditions, developing 
in the absence of a preceding history of gastric ulcer, can be distinguished 
as to their etiology only on the basis of probability and exclusion. 

The distinction between a chronic indurated gastric ulcer and gastric 
carcinoma may be impossible both clinically and at operation. The 
subsequent course of these cases shows that even careful microscopic 
examination may leave the examiner in error. Hence, when radical 
surgical procedure is possible, this in doubtful cases should take the form 
applicable to cancer. 

Carcinoma of the Stomach. — Carcinoma of the stomach is an affection 
of middle age and old age without sex predilection, usually involving the 
pylorus and lesser curvature, and growing toward the stomach rather 
tian toward the duodenum. It may develop without symptoms other 
t^ian moderate pain and those of gastric indigestion, until a palpable tumor 
is found, unless the lesion is placed near the pylorus or cardia and causes 
obstruction. Under such circumstances the symptoms do not differ 
from those of obstruction thus placed due to other causes except for 
their rapid (weeks or months) and inevitable progression. 

Apparently causeless and progressive loss of weight and toxic anemia 
in a person who has reached middle age, associated with persistent 
gastric pain of moderate severity, often localized tenderness, and gastric 
indigestion resistant to carefully regulated diet, are regarded as sufficient 
evidences of gastric carcinoma, particularly if associated with habitual 
absence or deficiency of hydrochloric acid and occult or obvious blood in 
the vomitus or the stomach washings. 

The symptoms upon which diagnosis is usually based are: Pain; 
emaciation; frequent vomiting of gastric contents, exhibiting the coffee- 
ground appearance of slight hemorrhage and deficient in hydrochloric 
acid, with lactic acid present and a large bacterial content, particularly 
the Oppler-Boas bacillus; later, vomiting of food taken many hours 
before, and with the demonstrable signs of gastric dilatation; and 



{ 



THE STOMACH AND DUODENUM 515 

finally, the detection of a tumor, hard, rounded, nodular, if the adjacent 
lymph glands are extensively involved, usually movable and best 
palpated when the stomach is empty. 

These, with the exception of tumor, are the symptoms of pyloric 
stenosis, and may be equally well marked from obstruction of equal 
degree due to other causes. When the symptomatology is complete and 
unmistakable the time for radical operation has generally passed. 

Hypochlorhydria is supposed to be particularly characteristic of cancer, 
and is noted even when this lesion is non-obstructive. Hydrochloric 
acid is subnormal in quantity, however, in many apparently healthy 
persons. 

The distinction between carcinoma and an indurated and obstructing 
ulcer can often not be made even at operation, the ultimate decision 
depending on microscopic examination. 

An early positive diagnosis of cancer can be made only by exploratory 
operation. 

Hourglass Stomach. — Hourglass stomach, possibly congenital, usually 
due to cicatricial contracture or infiltration of carcinoma, exhibits, as a 
rule, the constriction near the pylorus, the fundus being dilated. If the 
pylorus is also narrowed, both gastric pouches may exhibit dilatation. 
It is characterized by the symptoms of obstruction. The sudden return 
in quantity of turbid fluid through the tube after the stomach apparently 
has been washed clear is characteristic. Palpation and percussion of 
the inflated stomach at times give evidence of the condition. It is best 
detected by the x-trj after the ingestion of bismuth. 

When both the pyloric and the cardiac pouch are dilated even an 
exploratory operation may fail to reveal the true condition of affairs 
unless the exploration be thorough. 

Sclerosing Gastritis. — Sclerosing gastritis (linitis, rare) is characterized 
by an enormous fibrous thickening of the gastric w^alls, with consequent 
encroachment upon the lumen of the viscus. Its symptoms are those of 
inveterate gastric indigestion, pain, often severe, paroxysmal and most 
marked after eating, and vomiting, never profuse. It is slow in progress 
(years), the rigid gastric walls cannot be demonstrably inflated though 
efforts to accomplish this cause agonizing pain, and the hard, contracted 
stomach may be difficult to find even on exploration. 

Carcinoma of the Duodenum. — Carcinoma of the duodenum, rare as 
compared to this affection of the stomach, is, if obstructive, attended with 
the symptoms of pyloric stenos's, nor can it be differentiated except by 
exploration. 

When placed at or near the papilla, the symptoms are those of steadily 
progressing biliary obstruction, associated, in the absence of calculi, with 
little or no biliary colic, with a distended gall-bladder and the evidences 
in the stools of absent or deficient pancreatic secretion. 

Duodenal Ulcer. — Duodenal ulcer, an affection of middle-aged men 
(about forty years), developing usually on the anterior wall of the 
bowel near the pylorus, is probably symptomless, as a rule, its presence 



516 THE ABDOMEN 

not being suspected until the complications of perforation or hemorrhage 
occur. 

Diagnosis of the condition in the absence of these complications is 
based upon pain which, if localized, is often placed to the right of the 
ensiform cartilage and slightly below it, tenderness on deep pressure 
at this same point, and blood in the stools or the vomit, or both. Eruc- 
tation, recurring vomiting, and impaired general health are corroborative 
symptoms. The one which is most characteristic is the effect of food 
on pain ; the latter is relieved by eating a full meal, but recurs some hours 
later; vomiting and gastric lavage also give relief. 

The distinction between duodenal ulcer and hepatic colic is based 
upon the slower onset and less severity of the pain attacks of the former, 
the alleviating effect of eating, alkalies, vomiting, or lavage, the presence 
of blood in the stools or vomited matter, the usual hyperacidity of the 
latter, and constipation. 

The local tenderness and rigidity are in about the same region in 
both affections and in each jaundice may be present; the backward 
and upward radiations and pain on deep pressure are characteristic of 
hepatic colic, while referred surface pain and hyperalgesia in the right 
upper abdominal quadrant are more marked in ulcer. 

THE LIVER. 

The liver occupies the right upper abdominal quadrant, extending 
about two inches beyond the midline into the left upper quadrant. 
The surface marking of its upper border, which is moulded to the 
diaphragm, forms a curved line convex upward, extending from a point 
one and a half inch to the left of the base of the ensiform to a point half 
an inch below the right nipple (middle of the fourth intercostal space), 
thence to the ninth interspace in the scapular line. Its lower anterior 
margin corresponds with the costal border and a line drawn from the 
ninth costal cartilage to a point two inches to the left of the base of the 
ensiform cartilage. 

The liver is held in place by intra-abdominal pressure, by the falciform 
ligament extending practically from the diaphragm to the umbilicus and 
completely dividing the subphrenic space into two parts, and by its vascular 
attachments to the vena cava. 

The blood supply of the liver is through the hepatic artery. The portal 
vein brings blood from the spleen, pancreas, and gastro-intestinal tract. 
These two systems finally merge into the hepatic veins, which are without 
valves and which empty directly into the vena cava. 

The lymphatics empty into infradiaphragmaticand supradiaphragmatic 
nodes placed about the vena cava, into those placed about the celiac axis, 
and into those lying in the region of the cardiac end of the stomach. 

The nerve supply is from the solar plexus, the left pneumogastric, and 
the right phrenic. 

The gall-bladder, a diverticulum from the gall tract, from three to 
four inches long, with a capacity of one and a half ounces, lies with its 



THE LIVER 517 

fundus nearest the anterior abdominal wall at the point of crossing 
the costal margin by a line drawn from the right nipple in the male 
to the umbilicus (ninth costal cartilage). It is usually attached to 
the liver along its upper surface. Occasionally it is provided with a 
distinct mesentery. Its duct, about one and a half inches long, 
often sharply angled as it enters the common duct, presents a lumen so 
obstructed by mucous folds as to make the passing of a probe difficult 
or impossible. 

The gall-bladder is an unessential organ, provided with elastic but 
extremely strong walls. It is probably a provision for a continuous 
slow secretion, which is intermittently stimulated to hyperactivity when 
it is needed in the process of duodenal digestion. It has a secretion of 
its own independent of the bile which it contains. 

In the transverse fissure of the liver, two ducts, each coming from 
its own lobe, unite to form the hepatic duct, w^hich, after a course in 
the gastrohepatic omentum of from one to two inches, is joined by 
the cystic to form the common duct. 

The common duct passes dow^nward, either through the head of the 
pancreas or between this organ and the duodenum, and, after dilating 
into the ampulla of Vater and being joined by the pancreatic duct, 
discharges through a narrow, valve-like opening into the lumen of the 
duodenum. 

Along the course of the common duct, and particularly at the angle 
or junction between the cystic and the hepatic duct, are found lymph 
glands. 

The liver secretes two to three pints of bile in twenty-four hours. 
The flow is constant, but is increased by eating and by secretin. 

The bile is helpful, but not essential, to digestion. With the bile are 
excreted organisms, mostly dead, carried to the liver through the portal 
circulation, and at times toxic substances of such virulence as to cause 
ulceration of the intestine. 

Among the metabolic functions of the liver the formation of glycogen 
and urea are conspicuous. 

The cardinal symptoms of surgical liver affections are tenderness, 
pain, tumor, jaundice, gastric indigestion and the constitutional symp- 
toms of infection or impaired metabolism. ^Mien ascites, together with 
varicosities of the hemorrhoidal, superficial epigastric, and esophageal 
veins, develops the case is usually no longer a surgical one, though a 
stone pressing on the portal vein may cause these symptoms. 

The pain of liver affections is a dull ache, subject to paroxysmal 
exacerbation, often traceable to errors in diet. It is felt in the region of 
the liver or near the midline at the tip of the ensiform cartilage. Its 
radiation is toward the central line, backward or upward and backward, 
to the right, exceptionally to the left, shoulder (phrenic and superior 
acromial nerves). 

^^^len due to gallstone obstruction the pain is sudden in onset, ex- 
tremely severe, attended with early vomiting, which may or may not 
bring relief, and accompanied by tenderness in the gall-bladder region. 



518 THE ABDOMEN 

When due to acute inflammation of the investing peritoneum, the pain is 
attended with the tenderness and rigidity of local peritonitis. 

The tenderness of liver affections is elicited by direct palpation, and 
particularly in case of the gall-bladder by pressing the fingers of the 
examining hand deeply upward and backward in the gall-bladder region 
during expiration. The following inspiration will be abruptly arrested 
(Murphy). 

Tenderness thus elicited may be referred to the midline. 

Protective rigidity of the upper portion of the right rectus is in itself 
diagnostic of deep tenderness. 

The tumor of hepatic affections is detected by direct palpation and 
by percussion, the area of dulness being convex upward when due to 
solid growths or fluid accumulation below the diaphragm. 

Jaundice, earliest detected in the serum of blood drawn into a capillary 
tube and in. the urine and first seen in the conjunctiva, is a symptom 
of obstruction of the ducts. It is usually absent in stones confined to the 
gall-bladder, ephemeral when due to catarrhal swelling; is inconstant in 
abscess or neoplasm, or granuloma, depending upon the amount of 
direct pressure; is intermittently recurring and attended with paroxysms 
of pain in gallstone disease involving the common duct; is persistent and 
slowly progressive in carcinoma or chronic inflammation of the head of 
the pancreas, or in duct cancer. 

Malformation. — Transposition of the Liver. — ^This organ, being placed 
to the left side, is usually associated with malposition of other organs. 

An accessory lobe in the form of a tongue-like projection (RiedeFs 
lobe) extending downward over the gall-bladder in itself causes no 
symptoms. Its smooth outline, rounded borders, position immediately 
beneath the abdominal wall, attachment to the liver, and free respiratory 
movements are characteristic. 

Corset Liver. — Corset liver is characterized by the formation of a 
constriction in the right lobe, dividing this portion of the liver into two 
masses separated by a groove. It is usually observed in women given 
to tight lacing. The diagnostic symptoms are those of RiedeFs lobe. 

Movable Liver. — Movable liver, hepatoptosis, usually associated with 
general visceral ptosis, is characterized by a downward displacement 
with forward rotation of the diaphragmatic surface of the organ. The 
characteristic sharp edge and smooth, dome-like surface associated with 
percussion resonance in the liver region establish the diagnosis. 

Trauma of the Liver. — Severe subcutaneous injury is characterized 
by shock and symptoms of hemorrhage, the liver being easily ruptured 
because of its friability and bleeding freely because of its vascularity. 
Absolute diagnosis must be made by operation. Rupture of the gall 
ducts has usually caused rapid jaundice and the symptoms of a subacute 
diffuse peritonitis. 

Symmetrical Enlargement. — Symmetrical enlargement of the liver 
appears most frequently in the form of cirrhosis, an expression of inter- 
stitial hepatitis due to alcohol and other forms of chronic poisoning. 
It is occasionally associated with peritoneal and intestinal tuberculosis. 



THE LIVER 519 

It is characterized by jaundice, big, tender, uniformly enlarged liver, 
and constitutional symptoms incident to this condition. 

The symmetrically enlarged amyloid liver consequent on prolonged 
suppuration, exceptionally in syphilitic infection, exhibits neither 
jaundice, pain, nor tenderness. The stool may be light colored because 
of the diminished secretion of bile. 

Passive congestion incident to venous back pressure from circulatory 
failure, especially that incident to tricuspid insufficiency, is characterized 
by tender, often pulsating, hepatic enlargement. 

Banti's disease or splenic anemia is characterized by enlarged liver, 
secondary to that of the spleen. This term probably includes a number 
of affections of different origin, among which may be mentioned cirrhosis 
of the liver with early splenic involvement, malaria, and congenital 
syphilis. 

Cysts, Tumors, and Infections of the Liver.— Echinococcus Cysts. 
— Echinococcus cysts are usually multilocular, placed in the right lobe 
on its upper surface, can be detected only by slow growth, and not 
then unless they approach the surface anteriorly, project upward at the 
expense of the thoracic cavity, or become acutely inflamed. 

Diagnosis must be made by operation. 

Dermoid cysts have been reported, but must be diagnosticated by 
operation. 

Carcinoma. — Carcinoma, usually secondary to cancer of the stomach, 
rectum, or breast, exceptionally primary, is characterized by dull, deep- 
seated pain, often some tenderness, and the detection of a nodular 
growth. The distinction from gumma must be made by the associated 
history and the result of the therapeutic test. 

Sarcoma. — Sarcoma, usually secondary, occurs, as a rule, in younger 
people, and grows more rapidly. The diagnosis depends upon the 
finding of a primary focus, usually upon operation. 

Angioma or Lymphangioma. — Angioma or lymphangioma (rare) 
might be suggested by marked changes in consistency and size without 
obvious cause. The diagnosis is usually formulated at operation or 
autopsy. 

SyphiUs of the Liver. — Syphilis of the liver in the form of a diffuse 
infiltration, producing a uniform enlargement, sometimes accompanied 
by nausea, vomiting, and fever, may simulate abscess. The diagnosis 
must be based on the history and the therapeutic test. 

Gummata form circumscribed hard tumors, palpable along the anterior 
border, which may or may not be painful and tender. The distinction 
from cancer by palpation is impossible, and must be based upon the 
previous history of syphilis, the presence of other specific lesions or 
traces of them, the absence of a primary or demonstrable cancer 
focus, or symptoms suggesting the presence of such a one and the 
beneficial effect of mercuric treatment. 

Tuberculosis. — Tuberculosis is always secondary, and the same is true 
of actinomycosis. In either case a tumor may form with the local and 
general symptoms of subacute abscess. Diagnosis depends upon micro- 



520 THE ABDOMEN 

scopic examination of the discharge, associated with the history of the 
case. 

Abscess. — Abscess of the Hver due to trauma, direct extension, or in- 
fection carried from the gastro-intestinal tract (appendicitis, typhoid 
ulceration, amebic dysentery), either through the portal vein, the lymph 
channels, or the common duct, or infection carried through the hepatic 
artery (osteomyelitis, pyemia), may be single or multiple, usually the 
latter, excepting when the abscess is secondary to trauma, direct ex- 
tension from perihepatic suppuration, or amebic dysentery. 

The condition is characterized by local pain, tenderness, usually general 
enlargement of the liver, and the gastro-intestinal, systemic, and blood 
symptoms of infection. Jaundice may or may not be present, but is 
usually observed to a slight degree. Pain and friction sounds of peri- 
hepatitis are at times noted. Upward extension is characterized by the 
symptoms of a basal pleurisy on the right side. This may be followed 
by purulent expectoration due to rupture of the abscess through the 
lung into a bronchus. Pain radiations are backward and upward. 

The symptoms in the case of single amebic abscess, usually placed on 
the upper surface, may remain latent for months, percussion demon- 
strating an increased area of dulness extending dome-like into the chest. 
The diagnosis is often not suspected until edema and tenderness indicate 
surface pointing. 

When the abscesses are multiple (suppurative cholangitis) the consti- 
tutional symptoms of profound infection far outweigh those of local 
reactive inflammation. 



THE GALL-BLADDER. 

The gall-bladder may be absent, bifid, or hourglass in shape. 

Injuries. — Injuries to the gall-bladder or ducts, barring direct wound, 
are not common, except in connection with extensive and usually fatal 
trauma to neighboring organs. The immediate usual sequel is peri- 
tonitis; in the absence of this, the evidence of free fluid in the peritoneal 
cavity and jaundice from bile absorption. 

Distention. — Distention of the gall-bladder may be due to the retention 
of its own secretion incident to blocking of its pelvis or duct, or to pro- 
longed backing of the bile into it because of obstruction to the common 
duct. 

It is characterized by the presence of a rounded, smooth tumor in the 
gall-bladder region, growing downward and inward toward the umbilicus, 
and usually neither tender nor painful. 

The position of the tumor above or in front of the colon and not pal- 
pable in the flank, its participation in the respiratory movements of the 
liver, and its attachment to the latter organ distinguish it sufficiently 
from renal enlargements. When the distention has become so great 
as to form a large tumor filling the greater portion of the right abdomen, 
or even overlapping the middle line, the distinction from renal tumor, 



THE GALL-BLADDER 521 

or even cysts of pelvic origin, is more difficult. The history of the de- 
velopment of the growth, the attachment of its pedicle to the liver, the 
comparatively moderate bulging in the flank, are all elements favoring 
its gall-bladder origin. This form of distended gall-bladder is usually 
not accompanied by jaundice, but, if the latter exists, it is moderate 
in degree. 

When the distention is due to obstruction of the common duct there 
is always associated an intense jaundice. 

Cholecystitis. — Cholecystitis, usually associated with calculi, may 
appear in the catarrhal, suppurative, or necrotic form. It is character- 
ized by pain, tumor, local tenderness and rigidity, and constitutional 
symptoms of infection. Often, also, by a moderate jaundice. 

The acute, suppurative form, commonly secondary to typhoid fever, 
pneumonia, or appendicitis, is characterized by pronounced symptoms 
of both local peritonitis and constitutional infection. 

Gangrene or perforation may be characterized by the development 
of either the symptoms of local abscess of hyperacute type, or those of 
diffuse peritonitis. 

Membranous cholecystitis exhibits much the symptoms of gallstone 
disease, i. e., colic and local tenderness and rigidity. This rare affec- 
tion might be suggested by the finding of membranes in the stools 
since it is associated with membranous enteritis. 

The rupture of a gall-bladder abscess may occur externally, usually 
below the border of the ribs or in the umbilical region, into the colon, 
the duodenum, the stomach, the subphrenic space, or the renal pouch. 

Cholelithiasis. — Stones in the Gall-bladder. — Stones, usually formed in 
the gall-bladder of physically indolent, gouty, fat people, particularly 
women (3 to 1) past the age of thirty-five, are due to infection which 
in turn is often secondary to typhoid fever or appendicitis. 

When there is no effort made to extrude them from the bladder, they 
may cause no symptoms other than heaviness after eating, gaseous 
eructations, deep pain, referred to gastric indigestion, and the symptoms 
of pyloric stenosis of moderate degree. 

When stones in the gall-bladder cause symptoms which may be 
regarded as diagnostic, they are expressed either in the form of pain, 
harassing, deep, diffuse, in the liver region, associated with gastric 
indigestion and often a dorsal reference (to the right of the eleventh 
and twelfth spinous processes); tenderness elicited by hooking the 
fingers under the rib at the ninth costal cartilage during expiration 
and directing the patient to take a deep breath, sometimes referred to 
the epigastrium; recurring fever paroxysms exhibiting a sudden jump 
and equally sudden drop of temperature, the steeple chart; or in the 
form of colic, characterized by the rapid or sudden onset of severe 
crippling often shocking pain in the liver region, with radiations back- 
ward and upward, tenderness readily elicited in the gall-bladder region 
unless the rectus be protectively rigid, nausea, vomiting, which may 
or may not bring relief, intestinal tympany, and constipation. 

Fever is present or absent in accordance with the degree of infection 



522 THE ABDOMEN 

and the completeness of obstruction. The attack may last minutes, 
hours, or days, and be paroxysmally recurrent in type. Convalescence 
is, considering the severity, astonishingly rapid and complete. 

Following the attack, soreness and tenderness last for several days. 
Relief of acute symptoms, prompt or gradual, signifies that an obstructing 
stone has become so no longer, either because it has passed on or has 
dropped back into the gall-bladder. 

In the cases characterized by constant or recurring pain, but not of 
crippling intensity, the distinction between gallstone and gastric or 
duodenal ulcer will depend upon the more nearly midline seat of pain 
and local tenderness in the latter conditions, the finding of obvious or 
occult blood in the material expressed from the stomach, or obtained 
by examination of the stools, the prompt, decided, and usually certain 
aggravation of pain incident to taking food in the case of gastric ulcer, 
its immediate alleviation and subsequent (one or two hours) exacerba- 
tion in case of duodenal ulcer, the more pronounced effect on general 
nutrition of ulcer, and the prompt and usual relief incident to vomiting 
or the administration of chloretone. 

Catarrhal jaundice may be present in either duodenal ulcer or stone 
in the gall-bladder, and hyperchlorhydria is common to both conditions, 
particularly in the case of stone as a prodrome to an attack of colic. 

The pain due to efforts to pass a stone through the cystic duct, and 
the obstruction incident thereto is more sudden in onset and more 
crippling in intensity than that incident to ulcer. Attended as it often 
is with shock, vomiting, and tympany, it suggests rather a perforative 
peritonitis. The distinction from this condition is, in the early stages, 
suggested by the history of a previous attack, by the direction of pain 
radiation, and by the fairly sharp localization of tenderness over the 
gall-bladder; shortly by the absence of symptoms of a rapidly pro- 
gressing diffuse peritonitis. 

From renal pain gallstone colic is distinguished by its upward and 
backward pain radiations, absence of tenderness in the ileocostal angle, 
and usually by urinary findings in the latter condition. 

The distinction between hepatic colic and the abdominal crises of 
ataxia, of angeoneurosis, or the referred pain of thoracic infections is 
referred to elsewhere. 

Stones in the gall-bladder, or its duct, may be complicated by hydrops, 
or acute or chronic cholecystitis; usually when they excite symptoms, 
often in the absence of these, by local peritonitis with the formation of 
adhesions to the omentum, colon, stomach, and duodenum; occasion- 
ally by fistulous openings into hollow viscera, or pericystic abscess 
formation; occasionally by catarrhal cholangitis of sufficient intensity 
to cause intermittent jaundice; exceptionally by portal phlebitis, inci- 
dent to direct pressure, with ascites, and, if the common duct also be 
involved, pronounced and continuous jaundice. 

Stones in the hepatic or the common duct are characterized by much 
the same symptoms as those of stone in the cystic duct, with the usual 
addition of jaundice, either intermittent or continuous, which varies in 



THE PANCREAS 523 

intensity from day to day or even in the same day, which deepens 
with each attack of pain, and fever, coming on with the jaundice-pain 
paroxysms, intermittent in type, and exhibiting the steeple fluctuation, 
and deterioration in weight and strength, which may be rapid (weeks, 
months) or slow (years). 

The gall-bladder is usually contracted, adherent, and cannot be pal- 
pated; the liver is enlarged, often markedly so, and particularly during 
acute pain and jaundice attacks. The stools are putty colored and 
fatty and the urine is bile stained. 

Stones in the common duct are complicated by cholangitis, which 
may become widespread, suppurative, and rapidly fatal, by ulceration 
and abscess formation, or discharge into surrounding hollow viscera, 
by phlebitis and ascites, and particularly by acute, subacute, or chronic 
pancreatitis. 

From cholangitis, without stones, the diagnosis is mainly based upon 
the history of recurring attacks of pain. 

From obstruction of the common duct by malignant growth or pan- 
creatic infiltration, by the fatally progressive nature of the jaundice, 
in the latter case, the more complete and permanent occlusion of the 
duct as shown by examination of the stools, the palpable enlargement 
of the gall-bladder, and the absence of a history of recurring attacks 
of hepatic colic. 

Aneurysm of the hepatic artery may cause by pressure both the colicky 
pain, the gastric disturbances, and the jaundice characteristic of duct 
stone. Theoretically, the detection of a pulsating tumor, giving a 
characteristic bruit, should establish the diagnosis. 

Cancer of the Gall-bladder. — Cancer of the gall-bladder, usually due to 
stone, is characterized, aside from the symptoms of this latter con- 
dition, by nodular tumor in the gall-bladder region. Diagnosis should 
be made by operation and before tumor becomes demonstrable. 

Gall-bladder cancer, secondary to infiltration of the liver, usually 
gives no history of stone, and is of minor moment as compared to the 
primary disease. In either case, if the cystic duct be occluded, acute 
suppurative cholecystitis, with its characteristic symptoms, may develop 
and mask the original lesion. 

Occlusion of the common duct by cancer of the papilla cannot be 
distinguished from that due to stone, since it is usually secondary to 
this condition, except for the lack of intermittence in obstructive symp- 
toms and the development of ascites from vein involvement. The 
complicating gastric disturbance, the constitutional manifestations of 
cholangitis, and the symptoms and signs of pancreatic involvement, are 
the same in both affections 



THE PANCREAS. 

The pancreas is a lobulated, postperitoneal gland, without fibrous 
capsule, the head of which fits into the loop made by the V-shaped duo- 



524 THE ABDOMEN 

denum or may completely surround this portion of the gut, and the neck 
and body of which pass almost transversely across the abdomen behind 
the stomach on a level with the body of the first lumbar vertebra about 
three inches above the umbilicus. There may be aberrant growths 
of normal tissue connected with the substance of the gland by ducts 
only, or an accessory pancreas without any connection with the gland 
may develop in the gastric or intestinal walls. 

The main duct, the canal of Wirsung, traverses the entire length of 
the gland, parelleling the common bile duct as it approaches the latter 
and finally uniting with it in the duodenal wall to form the ampulla of 
Vater. The accessory duct (duct of Santorini), communicating with the 
main duct at the neck of the gland and collecting the secretion from its 
head, discharges into the duodenum by a separate orifice placed about 
three-quarters of an inch above the opening of the ampulla of Vater. 

The common bile duct and the pancreatic duct may unite at some 
distance from the duodenum or may open side by side at the apex of 
the caruncle. 

Between the head of the pancreas and the duodenum, or completely 
surrounded by pancreatic tissue, lies the common bile duct. The pan- 
creas is encircled by anastomosing arteries derived from the splenic 
hepatic and superior mesenteric vessels; the veins pass directly into 
the splenic and superior mesenteric veins. Nerves are from the vagi and 
the solar plexus. The lymphatics pass into the duodenal, superior 
mesenteric, and splenic glands. 

The function of the pancreas, aside from an internal secretion effecting 
carbohydrate metabolism, is the secretion of from half a pint to a pint 
of alkaline juice daily, the quantity varying in proportion to that of the 
acid chyme passed from the stomach. The acid chyme forms secretin 
from the duodenal epithelium, which in turn excites the pancreatic 
cells to activity. 

The pancreatic fluid is the universal digestant except for connective 
tissue, acting with vigor upon fats, particularly when the latter are mixed 
with bile and hydrochloric acid. Its proteolytic ferment, trypsinogen, 
is not activated into trypsin until it reaches the duodenum and becomes 
mingled with enterokinase. Its diastatic ferment is not observed in the 
first few months of life. 

Affections of the pancreas are characterized by pain, tumor, tender- 
ness, interference with function, and metabolism. 

Pain in acute pancreatitis is shocking in severity, is often attended 
with pronounced dyspnea, and is usually placed in the epigastric region. 
The pain of chronic pancreatitis is at times recurrent and severe, or 
may be absent. Any rapid growth or infiltration or arteriosclerosis 
may occasion paroxysms of agonizing pain. A backward and upward 
radiation of pancreatic pain has frequently been noted; exceptionally 
it has been downward to the right iliac region or even along the course 
of the sciatic nerves. The epigastric tenderness is extreme in acute 
cases, and is usually accompanied by the rigidity of peritonitis. In 
chronic inflammations midline tenderness on deep pressure is usual. 



THE PANCREAS 525 

Robson states that in thin persons with relaxed abdominal walls, 
and especially in those with ptosed stomachs, the body of the normal 
pancreas can be readily defined by palpation in the epigastric region, 
and that in both acute and chronic inflammation a distinct swelling 
can often be felt, giving a communicated, non-expansile pulsation 
and slight respiratory movement. The head of the gland is so deeply 
placed that the enlargement must be great before it can be detected 
by palpation. 

Interference with function and metabolism is most characteristically 
marked by large, foul, dirty white, acid, fatty stools, containing often 
undigested muscle fibers. Such stools are distinctly altered for the 
better by administration of pancreatic emulsion by the mouth. 

The neutral fat is much in excess of the combined fatty acids. In 
steatoma of biliary origin the quantities are more nearly equal, the 
combined fatty acids being somewhat in excess. 

Distaste for food, particularly for fats and meats, the symptoms of pro- 
nounced and inveterate indigestion, loss of weight, rapid in the case 
of neoplasm, usually marked anemia, oxalates, acetone, and diacetic acid 
in the urine, in inflammatory cases the pancreatic reaction (Cammidge), 
a tendency toward spontaneous hemorrhage or bleeding long continued 
from slight wounds, occasionally glycosuria. These are symptoms which 
when grouped strongly suggest extensive involvement of the pancreas. 

Growths of the pancreas occlude, either by their mechanical bulk 
or by infiltration, the common duct, the portal vein, or the duodenum. 

Injuries of the Pancreas. — If extensive, injury is usually associated 
with lesions of neighboring organs and exhibits no characteristic symp- 
toms. 

Abscess or cysts may develop subsequently as a result of exuda- 
tion into the lesser peritoneal cavity, with closure of the foramen of 
Winslow. Post-traumatic cysts usually grow directly from the pancreatic 
substance. 

Pancreatitis. — Pancreatitis, predisposed to by traumatism or obstruc- 
tion, congestion or hemorrhage, caused directly by infection extending 
from the common duct or duodenum, exceptionally carried by the 
blood and still more exceptionally due to extension from the adjacent 
organs, may be acute or chronic. It is usually secondary to chole- 
lithiasis, and primarily or secondarily hemorrhagic. 

Acute pancreatitis is characterized by the rapid or sudden onset of 
agonizing epigastric pain attended with shock or even collapse, dyspnea, 
cyanosis, painful vomiting, and epigastric tenderness and tympany. 
The tympany shortly (hours) becomes general, and there is often an 
associated slight jaundice, which, if the affection is secondary to common 
duct stone, may become pronounced. Referred pain is to the back 
between the shoulders or below the angle of the scapula on the left 
side, often to the precardial region or the right inguinal fossa. 

Following the acute onset, if there be a reaction from shock, the 
general tenderness and tympany, muscular rigidity, feeble or absent 
peristalsis, constipation^ and recurring vomiting indicate a diffuse 



526 THE ABDOMEN 

peritoneal irritation. The affection is commonest in fat men with a 
previous history of chronic indigestion, the latter doubtless secondary 
to an unsuspected chronic inflammatory condition of the pancreas. 

Acute pancreatitis may occur in the course of mumps; marked by 
vomiting and epigastric pain and sometimes definite tumor. This 
form of pancreatitis is less violent in onset than the hemorrhagic type, 
the symptoms are transitory and the prognosis is good. 

The framing of a prompt diagnosis is usually based upon the shocking 
severity of onset, the high midline pain, tenderness and tympany, 
pain radiation backward and to the left, and the finding of areas of 
fat necrosis at exploratory section. The latter have been found in the 
absence of pancreatic involvement (Fawcett). 

Later (hours, days), the symptoms of hyperacute diffuse peritonitis 
which usually follow gastric or duodenal perforation are wanting, though 
the belly is generally swollen, tender, and moderately rigid, and peri- 
stalsis is feeble. The feces contain an excess of fat and the urine gives, 
according to Robson and Cammidge, the pancreatic reaction which they 
regard as diagnostic. Sugar in the urine is exceptional. 

The pain of biliary colic has usually right radiations, and the tender- 
ness is placed to the right of the median line. Since the two conditions 
are often associated, a differentiation may be impossible. 

Abscess of the Pancreas. — Abscess of the pancreas, usually secondary 
to gallstones and cholangitis, may have an onset suggesting hemorrhagic 
pancreatitis, with symptoms less marked, particularly those incident 
to shock or collapse. Tenderness over the pancreas, absence of marked 
general tympany and diffuse peritoneal irritation, the detection of tumor, 
constitutional symptoms of infection, rapid loss of weight and the 
evidences of pancreatic involvement shown by examination of the urine 
and the stools will be elicited. The recurring paroxysms of pain and 
vomiting closely simulate those due to gallstone with which this con- 
dition is often associated. 

Catarrhal Pancreatitis. — Under this caption, Robson and Cammidge 
describe an affection which they believe a cause of acute and chronic 
catarrhal jaundice of non-calculus origin, the obstruction to the com- 
mon duct being not within its lumen but due to pressure of the swollen 
pancreatic head. They state that catarrh of the pancreas can be usually 
verified by digestive and metabolic signs and by swelling of the gland, 
which can, in some cases, be recognized by palpation through the 
abdominal wall, but in others only by manipulation of the pancreas 
through the open abdomen. 

Suppurative Catarrh. — Suppurative catarrh is a term employed by 
Robson to designate a pancreatic condition similar to suppurative 
cholangitis, with which it is usually associated. The symptoms are 
essentially septic, and the diagnosis of pancreatic involvement is 
apparently dependent upon the presence of the pancreatic reaction 
in the urine. 

Chronic Pancreatitis. — Chronic pancreatitis, usually incident to long- 
standing obstruction, associated with catarrhal inflammation, hence a 



THE PANCREAS 527 

common accompaniment of common duct stone, but occurring in the 
absence of this, is characterized by progressive wasting (months, years), 
inveterate gastric indigestion, tenderness on midUne on deep pressure, 
the tumor lying behind the stomach and carrying aortic pulsation, pain 
paroxysms with left posterior radiations, persistent and steadily deepen- 
ing jaundice in the late stages, and, when the common duct passes 
through the hardened pancreatic head and the gall-bladder has not 
been previously diseased, painless enlargement of this viscus. 

The laboratory examination should show pancreatic reaction, oxa- 
luria, and, in the late stages, an excess of neutral fat and often free fat 
globules in the large pale, offensive stools. 

The distinction from cancer of the pancreas may be impossible even 
at operation, though the usual painless onset, comparative rapidity in 
progress (months), age incidence (over forty), completeness of obstruc- 
tion, ascites, hemorrhoids, and tendency to bleeding are characteristic 
of cancer. Pancreatic reaction is usually absent in this latter condition, 
unless there be an accompanying inflammation. 

Pancreatic sclerosis associated with a similar condition of the liver, 
incident to syphilis and tuberculosis, and as a consequence of arterio- 
sclerosis, is observed. 

Pancreatic Calculus. — Pancreatic calculus (rare) is distinguished by 
the symptoms and the urinary and fecal findings of subacute pancrea- 
titis. Recurring paroxysms of vomiting and severe pain with posterior 
or left radiation are recorded. The diagnosis is based upon x-rsij exami- 
nation, which shows these stones, since they are made up of lime salts, 
particularly the carbonate. Jaundice will develop if the stone impinge 
upon the common duct or be lodged in the ampulla of Vater. 

Pancreatic Cysts. — Pancreatic cysts, frequently following trauma by 
months or years, and usually attended with pain, tenderness, and gastric 
indigestion with recurrent exacerbations, are marked by the formation 
of a tense rounded tumor, the deep origin of which is demonstrated 
by inflation of the stomach or colon, or both. The tumor is slightly 
movable, may extend forward above or below the stomach, behind or 
even below the colon, and may cause obstructive symptoms from 
mechanical pressure, and gives in the urine the pancreatic reaction 
(Robson). Except it reach huge size it has little tendency to present 
in the flanks. 

The diagnosis of the pancreatic origin of such cysts is, even at 
operation, not always possible, though the presence of the pancreatic 
ferments, other than the diastatic, in the evacuated fluid may be 
regarded as positive evidence. These ferments are usually absent. 
Characteristic alteration in the urine and feces and jaundice will depend 
upon the amount of destruction of pancreatic tissue and the pressure 
effects of the tumor on the main ducts. 

Cancer of the Pancreas. — Pancreatic cancer, usually of the scirrhous 
type, and occurring after the fortieth year, is characterized by rapid 
(months) loss of weight and strength, progressive anemia, and, if the 
head of the gland is affected, painless jaundice with swollen liver and 



528 THE ABDOMEN 

non-sensitive, enlarged gall-bladder; large, fatty, pale, offensive stools, 
with excess of neutral fat over combined fatty acids, and absence of 
stercobilin ; often edema of the feet and ascites, tendency to hemorrhage, 
and early fatal termination. The tumor, if felt, is fixed, hard, deep, 
and conveys aortic pulsation. The pancreatic reaction is usually 
absent, unless there be an associated pancreatitis. Extension to the 
liver and to the stomach is common. 

When the body of the gland is primarily involved, the tumor can 
often be readily palpated, its postgastric position being established 
by gastric inflation. At times the pain incident to pancreatic cancer 
is harassingly severe, with paroxysms of intensity associated with 
vomiting which suggest gallstones. When the body of the gland is 
involved, the referred pain is behind and to the left. 

From chronic sclerosing pancreatitis the rapid course of cancer is 
diagnostic, also in the former position the pancreatic reaction in the 
urine is always present, nor is the absence of bile and pancreatic juice 
in the intestinal contents ever as complete. Even at operation, how- 
ever, it may be impossible to distinguish between these two affections, 
the diagnosis then depending upon the result of conservatiye operation 
or autopsy. 

From syphilitic infiltration the diagnosis must depend upon the 
result of medicinal treatment suggested by the history. 

Since by its mechanical pressure pancreatic cancer may produce 
symptoms of pyloric stenosis, the distinction from cancer of the stomach 
may be diflicult ; the stools, however, in cancer primarily pyloric do not 
exhibit the characteristics of those devoid of pancreatic secretion, and 
the vomitus of the stomach lesion is usually characteristic, though in 
either case free hydrochloric acid is likely to be absent. 



THE SPLEEN. 

The spleen is a ductless gland, averaging 5 inches in length, 3 in 
width, 1^ in thickness, and 7 ounces in weight. It lies in the posterior 
part of the upper left side of the abdomen between the fundus of the 
stomach in front and to the right and the arch of the diaphragm behind ; 
it extends from the upper border of the ninth to the lower border of the 
eleventh rib, and its long axis corresponds to the back part of the tenth 
rib. It is limited in front by the midaxillary line and posteriorly it 
reaches to within 1^ inches of the spine. Its sharp anterior border is 
distinctly notched, forming a characteristic feature when it can be 
palpated. 

The organ is almost completely surrounded by peritoneum, and is 
held in place by the phrenosplenic ligament which connects it to 
the left crus of the diaphragm, and by the colon, which is held 
up by the phrenocolic ligament which forms a pocket-like support. 
Through the gastrosplenic ligament connecting this organ with the 
stomachy but affording no support to it, pass the vessels which are 



THE SPLEEN 529 

extremely large, entering the spleen on its anterior surface at the hilus. 
The splenic artery, which also supplies branches to the pancreas and 
the stomach, brealcs up into about half a dozen branches about an 
inch before it enters the spleen. The splenic vein unites with the 
superior mesenteric to form the portal vein. 

The nerve supply is from the solar plexus, and from the right pneumo- 
gastric. 

The spleen is brittle, highly vascular, and fairly mobile. ^Vhen 
normal it cannot be palpated, nor can it be satisfactorily percussed. 

The spleen of infants is relatively large, and in them can often be felt 
when normal. To palpate the spleen, the finger tips are pressed firmly 
just in front of the tips of the eleventh and twelfth ribs and the patient 
is instructed to inspire deeply. During this manipulation the abdominal 
muscles must be relaxed. In case of any considerable enlargement, the 
anterior border and the lower anterior angle of the spleen can readily 
be felt. 

Percussion dulness can be detected only in case the spleen is decidedly 
enlarged. 

The function of the organ remains unknown, but it is supposed to 
both produce and destroy red blood cells. It is not essential to life 
or health. 

The diagnosis of surgical affections of the spleen is based upon enlarge- 
ment or displacement; usually both. 

Enlargement is commonly an expression of systemic infection, blood 
dyscrasia, localization of infection or neoplasm. 

Enlargements due to systemic infection and blood dyscrasia are 
characterized by preservation of the splenic conformation, particularly 
of the notch. There is a projection beneath the left costal margin of a 
superficial mass, with no intestine in front of it, exhibiting respiratory 
movement, and, when comparatively small and not fixed, easily slipping 
back into its usual position. 

The lower part of the diaphragm, as it bulges forward on deep inspira- 
tion, has been mistaken for the spleen. 

Anomalies. — x\bsence, imperfect development, or supernumerary 
spleens give rise to no symptoms. The diagnosis can be made only 
by incision. 

Movable, or wandering, spleen, an affection of adults and rare, except- 
ing where the spleen is enlarged and the belly wall lax, is characterized 
by the presence of a tumor corresponding in outline with the spleen, 
extremely mobile, superficially placed, and readily reduced to the normal 
position of this organ. When a wandering spleen becomes fixed in a 
faulty position, diagnosis may be suggested by percussion resonance 
in the normal position of the spleen, but usually it is made only by 
operation. 

When a wandering spleen becomes twisted on its pedicle, the symp- 
toms are similar to . those of perforative peritonitis, that is, sudden, 
severe pain, vomiting, and shock. Diagnosis is based upon the history 
of a wandering spleen, if this be obtainable, and by the detection of 
34 



530 THE ABDOMEN 

a hard, tender mass. If rigidity and tympany obscure this tumor, 
diagnosis may not be made until an exploratory operation reveals the 
cause of the symptoms. As a complication of this condition, profuse 
bleeding may occur. When the vascular obstruction is not complete, 
the symptoms, pain, tenderness, and tumor are more distinctly char- 
acteristic. 

Traumatism. — Rupture. — Rupture of the spleen, except in associa- 
tion with other extensive visceral lesions, is rare when the organ is 
healthy. When it is enlarged, this accident is not uncommon, even 
from comparatively trifling violence because of its friability. Rupture 
has been known to result from muscular contraction. 

The diagnosis is difficult and not often made except at operation or 
necropsy. It would be aided by previous knowledge of enlargement of 
the spleen as well as by inquiry into the nature of the accident. The 
symptoms are, generally speaking, those of serious intra-abdominal injury. 
Most subjects suffer severe hemorrhage, which proves fatal, as a rule, 
within an hour. The abdomen is rigid, and percussion reveals fluid blood 
within its cavity. However, on account of the formation of large clots 
in the region of the spleen, the left side continues to give a dull note 
even when the patient is put on the right side; the right side, however, 
becomes resonant when the patient is put on the left side. This is 
known as Ballance's sign, and is pathognomonic of rupture of the 
spleen (Moynihan). There is a continuous severe pain over the 
splenic area. 

Wounds. — Wounds of the spleen are diagnosticated by the character 
of the wound, by the signs of internal bleeding, and by exploratory 
operation. 

Hypertrophy. — Hypertrophy of the spleen has been observed as an 
idiopathic affection. Diagnosis is based upon the absence of other 
causes of splenic enlargement, nor is the affection of surgical interest 
unless it be associated with displacement, torsion, or other accident. 

Congestion.— Congestion causes enlargement, often distinctly palp- 
able, in the course of affections of the lungs, liver, and heart. Diagnosis 
is based upon the adequacy of the primary condition to produce such 
condition. Aortic insufficiency complicated by an acute infectious 
disease may be accompanied by a pulsating splenic enlargement. 

Inflammations. — Splenitis. — Splenitis is a complication of infec- 
tion, particularly malaria and typhoid fever. It is characterized by 
enlargement which is a phase of the systemic disease. The • affection 
is usually transitory but may become chronic, particularly in the course 
of malaria. It is of importance when it is complicated by rupture, 
displacement, or torsion. In the case of syphilis there is often peri- 
splenitis accompanied by tenderness, pain, slight rigidity, and ultimately 
contractions, adhesions, and deformity. 

Acute Suppurative Infection of the Spleen. — This is a rare affection, 
usually secondary to suppuration elsewhere or to traumatism, or ty- 
phoidal or malarial infection. Pain, tenderness and tumor, with local 
peritonitis and the systemic symptoms of infection, are the dominant 



i 



THE SPLEEN 531 

symptoms. Splenic abscess usually opens into the general peritoneal 
cavity or the colon or kidney. It may burrow through the phreno- 
splenic ligament to the cutaneous surface or into the pleural cavity. 

Syphilitic Enlargement of the Spleen. — This occurs particularly in 
infants and children, and is the usual cause of enlargement in them. 
It may appear as an acute enlargement in the early course of the disease, 
as chronic indurative splenitis, or as a gumma. In the latter case the 
tumor is rarely of sufficient size to be detected. The diagnosis is based, 
as a rule, upon the effect of antisyphilitic treatment. 

Tuberculous Enlargement. — This is nearly always secondary to tuber- 
culosis in other parts of the body. The affection is usually masked by 
other abdominal symptoms. 

Cysts. — Hydatid cysts (rare) are always unilocular in the spleen, are 
usually associated with manifestations of the disease elsewhere, and have 
rarely been diagnosticated except at operation. 

Serous, blood, lymphatic, and dermoid cysts are extremely rare, and 
could be diagnosticated only by fluctuation or by operation. In con- 
trast with the parasitic cyst, these collections of fluid develop mainly in 
the lower part of the spleen, and hence become palpable before they 
reach very great size. 

Tumors. — Tumors are rare. They are characterized by irregular, 
usually nodular enlargement, commonly associated with pain and 
tenderness and not infrequently creaking due to perisplenitis. 

Sarcoma, the primary tumor most frequently observed, is charac- 
terized by its rapid growth. Carcinoma is secondary. Extremely rare 
tumors are lymphangioma, cavernous hemangioma, and fibroma. 

Splenic Anemia, or Banti's Disease. — A distinctly surgical affection, 
characterized by an indurated, often enormous, spleen, resulting from 
hyperplasia of the connective tissue and endothelial cells. The lym- 
phatic glands are not involved, nor is there a characteristic blood picture. 
There is an associated cirrhosis of the liver, usually of a hypertrophic 
type, secondary to the splenic enlargement. There is pain associated 
with profound weakness, muscular atrophy, hemorrhages, fever, 
together with the usual symptoms of anemia and later ascites. This 
affection is distinguished from the splenic enlargement secondary to 
hepatic cirrhosis by the much greater size attained by the spleen; from 
sarcoma by the slower course and the associated liver enlargement; 
from chronic malaria by the absence of malarial organisms and malarial 
history. From syphilis by failure to respond to treatment. From leuke- 
mia by the blood findings. 

Amyloid Degeneration. — Amyloid degeneration usually incident to 
prolonged suppuration and associated with a similar condition of the 
liver and kidneys, is characterized by uniform, indurated enlarge- 
ment. 

Leukemic Enlargement. — ^This occurs in the splenomyelogenous 
variety and is characterized by a soft, symmetrical tumor, later 
becoming hard and reaching an enormous size, accompanied by peri- 
splenitis and adhesions. Diagnosis is based upon the blood findings. 



532 THE ABDOMEN 

The leukocytes are enormously increased in number and many myelo- 
cytes are present. There is marked reduction and nucleation of red 
cells. 

The splenic enlargement of 'pseudoleukemia, or Hodgkin's disease, is 
accompanied by tumor of the lymphatic glands which begins in the 
neck, axilla, or groin. This in itself establishes the diagnosis. Aside 
from the reduced number of red cells and hemoglobin, the blood picture 
is not characteristic. 

THE INTESTINES. 

The jejuno-ileum, twenty-two feet long, lies in the central part of the 
abdominal cavity and in the pelvis, being bounded laterally and above 
by the large intestine. The mesocolon with the great omentum lies in 
front and more or less completely separates the small gut from the 
anterior abdominal parietes. At its beginning, where, forming a sharp 
angle with the terminal portion of the duodenum, it emerges from 
beneath the transverse mesocolon, it is held in fixed position by a mus- 
culofibrous band from the left diaphragmatic crus, the ligament of 
Trietz. 

The upper portion of the jejuno-ileum is thicker, larger, more vascular, 
darker in color, and more abundantly supplied with valvulse conniventes 
than is the lower part of the gut. The arterial loops of the upper part of 
the bowel are imperfectly developed, long straight vessels running directly 
to the gut wall (Monks). Passing downward, both primary and second- 
ary loops become well developed, being distinctly marked at about the 
fourth foot. Still lower, secondary and tertiary loops are observed; the 
latter progressively approach closer to the inner margin of the gut. 

The parietal mesenteric attachment of the small gut is about six inches 
in length, starting to the left of the spinal column at the duodenojejunal 
junction (body of the second lumbar vertebra) and running obliquely 
downward and to the right to a position in front of the sacro-iliac 
articulation. Between the two peritoneal layers of this mesentery 
course the vessels, nerves, and lymphatics. 

The arterial supply is through the superior mesenteric, the venous 
return is through the portal system. The nerves are derived from 
the celiac plexus and the pneumogastric; connections of the latter and 
the sympathetic with the lower dorsal segments, explain pain irradiations 
and muscular rigidity in cases of intraperitoneal affections. The nerve 
terminals communicate with two plexuses, that of Auerbach lying between 
the circular and longitudinal muscle fibers, and having control over 
motion, and that of Meissner, passing to the mucosa and dominating 
secretion and probably absorption. The lymphatic vessels, after passing 
through a series of mesenteric glands, one or two hundred in number, 
terminate in the thoracic duct. 

The function of the small intestine is essentially that of absorption of 
carbohydrates, fats, and proteids, excepting in its extreme upper part, 
where some secretin is produced. Its muscular coats by their con- 



THE INTESTINES 533 

traction occasion repeated rhythmic segmentation (Cannon) and pro- 
pulsion. These muscular motions, though they may be centrally 
stimulated or inhibited through the pneumogastric and sympathetic 
fibers, seem to be dependent in the main upon the action of intrinsic 
ganglia. 

On clinical evidence, in case of obstruction there seems to be a 
reverse peristalsis, by virtue of which the intestinal contents are thrown 
back into the stomach, though in many cases in which this is supposed 
to have taken place the vomited matter is in reality an expression of an 
enormous gastric transudate. 

In adults the ileocecal valve corresponds in its surface marking 
almost to the position usually given to the base of the appendix, i. e., 
one and one-half to two inches from the anterior superior spine of the 
ileum in a line toward the umbilicus. It may depart greatly from this 
position in accordance with the placing of the cecum. Its entrance into 
the large gut is at a right angle and is protected by a valve, the most 
efficient part of which seems to be a loose mucous flap opening toward 
the cecum and incompetent against sustained back pressure. 

The colon, beginning at the cecum and ending at the junction of the 
sigmoid flexure with the rectum (third sacral vertebra), has about twice 
the diameter at its beginning as in the terminal portion of its course. 
Its capacity up to six months of life is about a pint; up to the second 
year, between two or three pints; and in adults, about a gallon. The 
cecum, the transverse colon, and the pelvic colon (sigmoid flexure) are 
freely movable. The splenic flexure is placed far back and high, and 
is suspended by the phrenocolic ligament, which in turn acts as a 
support to the spleen. 

The colon is distinguished by its large size, its sacculated form, the 
presence of longitudinal bands and appendices epiploicse, and in the 
transverse portion by the attachment of the omentum. The pelvic 
colon (sigmoid flexure) exhibits neither sacculation nor longitudinal 
bands and normally lies in the pelvis. In the fossa made by the failure 
of its mesentery to completely unite with the peritoneum of the posterior 
wall hernia sometimes takes place. 

The cecum, lying below the entrance of the ileum into the colon, 
about two and one-half inches in length, often completely invested 
with peritoneum, is the largest and most superficial portion of the 
gut, lying in the right iliac fossa with its blind end about on a level 
with a line joining the two anterior superior spines of the ileum. 
From imperfect descent this portion of the gut may lie much above this 
position. In shape the cecum may be funnel-like, the appendix forming 
the small end of the funnel, or may exhibit symmetrical or asymmetrical 
pouches divided by the longitudinal bands. 

The appendix, originating at the termination of the longitudinal bands, 
usually about three inches in length, is a blind tube composed of a large 
quantity of lymphoid tissue, exhibiting a tendency to atrophy with ad- 
vancing years. It has a valve-like arrangement (the valve of Gerlach) 
at its colonic opening when it enters this viscus at an angle (Piersol). It 



534 THE ABDOMEN 

is provided with a mesoappendix coming from the left side of the mesen- 
tery and from the cecum, attached for a variable distance, and, because of 
its relatively short base, commonly causing either a coil or a twist in this 
organ. In women a second mesenteric fold sometimes extends from the 
broad ligament and contains a branch of the ovarian artery. 

In the mesoappendix lies the appendicular artery derived from the 
posterior branch of the ileocecal. The veins pass to the portal system, 
the lymphatics to the mesenteric, iliac, and postperitoneal groups. In 
the female the bloodvessels communicate with those of the ovary. The 
nerve supply is from the superior mesenteric plexus. 

The appendix is predisposed to disease because it is a rudimentary 
organ which contains an excess of lymphoid tissue, is poorly drained, 
and is subject to twists or turns which interfere with blood supply. 

The surface marking of the root of the appendix lies two to three 
inches from the right anterior superior spinous process of the ilium on 
a line passing directly to the corresponding bony process of the opposite 
side. 

The function of the colon is essentially that of absorption. Cannon 
has shown that there normally exists in its proximal part an antiperistalsis, 
i. e., waves of constriction running backward from the cecum. The 
contents of the transverse colon are almost as inspissated as those of 
the sigmoid. 

It is calculated that about 15 per cent, of the nutritive material and 
the greater part of the fluid of the bowel contents are absorbed by the 
large intestine. From the stomach downward the bacterial richness of 
the gastro-intestinal contents increases. 

General Symptomatology. — Surgical affections of the intestines are 
characterized by pain, tenderness, exaggerated, diminished, or absent 
peristalsis, the presence of mucus, blood, or pus in the stools, the symp- 
toms of acute or chronic obstruction, wasting and toxemia, and at times 
by palpable tumor. They are frequently complicated by local or diffuse 
peritonitis. 

The pain, attributed to a drag on the mesentery, since the intestine has 
no sensory nerves, is usually colicky in character, exhibiting remissions 
and exacerbations incident to distention and peristalsis. It may be a 
constant and localized ache. The tenderness is rarely acute, unless the 
peritoneum be involved. 

Exaggerated peristalsis is a symptom of acute irritation or of mechan- 
ical obstruction; in the latter case it is associated with muscular hyper- 
trophy if the obstruction be chronic and incomplete. There is an 
exaggerated peristalsis of psychic origin easily recognized as such. 
Absent peristalsis may be of central origin; it is usually due to peri- 
tonitis. Mucus in the stools is nearly always a proof of catarrhal 
inflammation. Blood is often occult, and is then detected only by careful 
chemical examination of the stools after a meat-free diet. 

Congenital Anomalies. — ^Transposition and malposition of the intes- 
tines in the absence of obstructive symptoms cannot be diagnosticated 
without operation, except in the case of the descending colon and 



THE INTESTINES 535 

sigmoid, when rectal insufflation or injection with bismuth, followed by 
the use of the arrays, will demonstrate the condition. 

Obstruction developing shortly after birth, if persistent, is, in the 
absence of inflammatory symptoms, characteristic of narrowing or 
occlusion. The diagnosis must be made by operation. 

Opening of the bowel in an abnormal position (vagina, urethra, 
bladder) will be denoted by characteristic symptoms. Meckel's diver- 
ticulum is at times congenitally patent at the navel, and from it will be 
discharged fecal matter, and about the umbilical ring will be found the 
mucous membrane of this diverticulum firmly attached. 

Hernia of the colon into the thorax through a congenital defect, if 
detected in the absence of obstructive symptoms, would be characterized 
by encroachment upon the lung capacity varying in extent at different 
times and by gurgling and peristaltic sounds preternaturally clear on 
direct auscultation. 

Idiopathic dilatation of the colon (Hirschsprung's disease) an affection 
of infancy and childhood, which involves mainly the pelvic colon (sig- 
moid), though the gut immediately above is often similarly affected, is 
due to defective development of the intestinal walls and is characterized 
by an obstinate and persistent constipation, which yields more readily 
to rectal stimulation than to medicine by the mouth, and by a bulbous, 
tympanitic belly practically filled by the dilated loop of gut. The rectal 
tube passed high usually drains some fluid feces. 

The diagnosis is based upon rectal inflation, and upon the a'-ray 
picture after bismuth injection of an obstinately constipated child with 
a chronically bulging, tympanitic belly. 

Ulcer. — Simple ulcer may occur in either the large or the small 
intestine and particularly in the latter. It exhibits raised indm-ated 
edges and is of obscure etiology, though doubtless started in some cases 
by fecal stasis. It has been noted in the course of nephritis and after 
poisoning by mercury. 

The symptoms are persistent localized pain, and tenderness on deep 
pressure, intestinal indigestion, and obvious or occult blood in the stools. 
Later, as a result of cicatricial contraction, the gurgling, constipation, 
colicky attacks, exaggerated peristalsis, and tympany of chronic obstruc- 
tion may develop. 

Peptic ulcers of the jejunum following gastrojejunostomy, more 
common in men than in women (Gosset), and not observed after opera- 
tion for cancer, are characterized by severe recurring pain, local tender- 
ness, and blood in the stools, vomiting being rare; or by symptoms of 
acute perforative peritonitis, in some cases occurring without previous 
symptoms, in others preceded by pain and tenderness and rigidity. 

Dysenteric ulcerations of surgical import are characterized by pain, 
tenderness, bloody stools, profound systemic depression, and usually the 
finding of the characteristic ulcerations by proctoscopic examination. 

Tuberculous ulceration, usually secondary to pulmonary consumption, 
in its diffuse form characterized by diarrhea, the stools containing occult 
blood, and at times by the symptoms of local peritonitis, is not a surgical 



536 THE ABDOMEN 

affection. Single or multiple tuberculous ulcers, affecting by preference 
the small intestine, often involving both the small and the large, may 
perforate, in which case they are characterized by the symptoms of acute 
perforative peritonitis. More commonly they heal, and, as the long 
diameter of these lesions lies at right angles to that of the bowel, they 
are prone to produce stenoses which may be single or multiple, and 
characterized by the symptoms of chronic obstruction (see p. 481). 
They usually develop between the twentieth and thirtieth year in 
persons giving a tuberculous history or exhibiting signs of tuberculous 
lesion elsewhere. 

Syphilitic ulcer is unattended by symptoms other than those of intestinal 
indigestion. Theoretically, persistent occult blood in the stools, associ- 
ated with a normal rectum and a history of syphilis, might suggest the 
diagnosis. The resultant stenosis would be characterized by symptoms 
of chronic obstruction. 

Typhoid ulcer becomes a surgical affection only when it perforates or 
threatens so to do. 

This accident commonly occurs in the third week of the disease, though 
it may be noted at any period, nor has it a relation to the severity of the 
fever. The perforation is usually single, occurring in the lower part of 
the ileum. 

The most characteristic feature of this complication is the sudden 
onset of agonizing, shocking pain, usually referred to the lower right 
abdominal quadrant, the almost immediate development of a weak, 
rapid running pulse, and a sudden drop in temperature. Neither 
vomiting, flank dulness, nor absence of liver dulness are of service in 
forming an early diagnosis. In some cases there is a rapid and marked 
increase in the number of leukocytes. Probable diagnosis is further 
confirmed by the rapid development of the tenderness, tympany, 
rigidity, and regurgitant vomiting of diffuse peritonitis (see p. 478). 
Its symptomatology is the same as that of perforation of an acutely 
infected gall-bladder, of a suppurating mesenteric gland or of a gan- 
grenous appendix, each an occasional complication of typhoid fever. 

The distinction between perforation and hemorrhage is based upon the 
rapid progressively weak pulse of the latter condition, unassociated with 
the severe pain of perforation; and shortly by the rectal evacuation of 
blood. Neither local tenderness nor rigidity is marked. The reaction 
from hemorrhage is usually prompt and well marked. 

From appendicitis the distinction would be based upon the slower 
onset, absence of primary shock, milder local and general symptoms 
and their stationary character for a time (hours or days). The differ- 
ential diagnosis has frequently been made only by operation. 

Cholecystitis, a common complication in typhoid fever, exhibits severe 
pain, placed, however, in the right hypochondriac region, and often 
referred to the back and shoulder, associated with almost immediate and 
persistent vomiting. It does not exhibit the symptoms of primary shock 
and there can be demonstrated a tenderness, rigidity, sometimes a tumor 
in the region of the gall-bladder. 



THE INTESTINES 537 

Right-sided pneumonia and pleurisy are customarily not attended by 
such marked primal shock. Vomiting, tympany, tenderness, and rigidity 
may all be present, but the latter two signs, the ones of cardinal impor- 
tance, are more marked on superficial than on deep pressure, nor are 
they by any method of examination developed in as typical a form as 
when they indicate an underlying peritonitis; respirations are hurried 
out of proportion to the temperature, and after a brief time the local 
signs of lung involvement can be elicited. 

Iliac and femoral thrombosis are less stormy in onset and more 
suggestive of appendicitis, since they may be characterized by right 
iliac pain, tenderness, and rigidity. The primal shock is wanting, and 
there is an elevation in temperature rather than a sudden drop. The 
symptoms are rarely so violent as to justify an immediate operation; 
as a rule, they lead to a suspicion of deep-seated abscess rather than 
acute diffuse peritonitis. 

Tumors and Infiltrations of the Intestine. — Of the benign tumors, 
polypoid adenoma is the commonest form. An afi^ection of youth, it 
is often multiple, and is usually detected only in the course of operation 
necessitated by its complications, i. e., invagination, obstruction by 
bulk, or, rarely, hemorrhage. Exceptionally it may attain a size suflfi- 
ciently great to be detected by palpation. 

Such a tumor occurring in an adult cannot be distinguished from 
malignant growth except by operation unless there be a history of its 
long continuance (years) and slow growth. 

Lipoma and Myoma .^ — Lipomata and myoma ta (rare), subserous in 
origin and not projecting into the lumen of the bow^el, may reach large 
size without symptoms other than that of a palpable and usually freely 
movable tumor. 

Diagnosis is suggested by the slow development (years) of these 
tumors. It should be made by operation, since they are prone to 
undergo malignant degeneration. 

Sarcoma. — Sarcoma of the small and large intestine can be distin- 
guished as such only by operation, often not until microscopic sections 
have been made. In general terms a sarcoma develops in younger 
people, grows more rapidly, invades the gut more extensively, contracts 
adhesions to surrounding structures more widely, gives metastasis to 
the liver and other intraperitoneal organs more promptly, and kills 
sooner than carcinoma. Moreover, in a fair percentage of cases it 
reaches larger size before obstructive symptoms develop. A pseudo- 
leukemic growth may start in a Peyer's patch. 

Carcinoma. — Carcinoma, rare in the small intestine, has for its seat of 
preference, if the rectum be excepted, the ileocecal junction, thereafter 
the sigmoid and the splenic and hepatic flexures of the colon. 

Glandular epithelioma, the common type, occurs in middle life (forty 
to sixty years), with many exceptions to this rule, and is slow in giving 
glandular extension or remote metastases. In the early stages there are 
no symptoms; exceptionally deep-seated, localized pain, and persistent 
tenderness and occult or obvious blood in the stools. 



538 . THE ABDOMEN 

The diagnosis is usually based upon irregular gaseous distention, con- 
stipation alternating with diarrhea, recurring colicky pains, persistent, 
gaseous gurgling, exaggerated peristalsis, local tenderness, and the 
detection of a tumor usually movable. When the splenic or the hepatic 
curvature is involved, it is usually impossible to palpate the tumor, 
even though it be carcinoma of large size (small fist). Rectal inflation 
may make a sigmoid tumor obvious which could not be felt otherwise. 
An attack of acute obstruction is sometimes the first symptom. 

Tuberculosis of the Intestine. — ^Tuberculosis of the intestine may be 
primary or secondary. In its secondary form, which rarely produces 
stenosis, it appears as multiple ulcers, their presence being suggested 
by colicky pains, intestinal indigestion, and occult or obvious blood in 
the stools. The mesenteric glands may be involved, and tuberculous 
peritonitis at times complicates the condition. The diagnosis is sug- 
gested by the progressive development of intestinal symptoms in a 
person suffering from pulmonary tuberculosis. 

Tuberculosis of the intestine in the localized hypertrophic form, 
having its seat of preference about the ileocecal valve, developing at 
times in the sigmoid, is usually primary in the cecum and extends 
along the ascending colon. The appendix may be greatly thickened or 
atrophied and obscured by a connective tissue and fat outgrowth. 

The early symptoms are those of intestinal dyspepsia, i. e., flatulence, 
colicky pains, and, not infrequently, alternating diarrhea and constipation. 
In the ulcerative type these symptoms are referred to the seat of involve- 
ment, usually the right iliac fossa, and an inflammatory tumor is associated 
with tenderness to deep pressure and often muscular rigidity. Fistul^e 
opening externally into the general peritoneal cavity are rare. In the 
hypertrophic type a hard, cylindrical mass forms, either preceded or 
followed by symptoms of chronic obstruction. This tumor may be 
movable or bound down. 

The distinction from carcinoma is based upon the comparative youth 
of those affected, the slow course of the disease (years), and the finding 
of tubercle bacilli in the stools. Even at operation the condition may 
so closely simulate carcinoma that the distinction can be made only by 
microscopic examination. 

From actinomycosis the distinction must be made by bacteriological 
examination of either the discharge or an excised mass. 

The distinction from chronic appendicitis can be made only by opera- 
tion. 

Diverticulitis. — Acquired diverticulitis may occur in any part of the 
intestinal tract, including the vermiform appendix. Its usual seat is 
the sigmoid flexure, the diverticula projecting into the appendices epi- 
ploicse or through the openings for the bloodvessels at the mesenteric 
attachment. Constipation seems a predisposing factor, and middle- 
aged or old fat men, or those who have been fat (Telling), are especially 
subject to the formation of diverticula. The diverticula are usually 
filled with feces, often contain concretions, and may become inflamed, 
gangrenous, or perforate. 



THE APPENDIX 539 

The most important and characteristic result of multiple diverticulitis 
is a chronic proliferation of the submucous and subserous coats of the 
bowel resulting in stenosis, tumor formation, and mimicry of carcinoma 
(Telling) so close that the more benign nature of the affection may not 
be recognized, either at operation or necropsy (Moynihan). The gut 
exhibits at most fistulae or abscesses, never a fungating ulcer. 

The diagnosis must be made by operation; at times by microscopic 
section of the excised mass. 

The inflammatory, suppurative, and adhesive complications are char- 
acterized by symptoms precisely like those of appendicitis, but are 
placed on the left rather than on the right side of the belly. A fistu- 
lous communication with the bladder and resultant cystitis is noted in 
10 per cent, of the recorded cases. 

The distinction between diverticulitis and tuberculosis of the hyper- 
plastic type must be made by microscopic examination of the excised 
gut segment. 

Impaction of feces (rare excepting in its rectal form) usually occurs 
in the pelvic colon or proximal to the splenic flexure, and is character- 
ized by constipation alternating with diarrhea, vomiting, the systemic 
symptoms of intestinal toxemia, and the formation of a tumor which 
can be moulded and changed in conformation by deep, continued 
pressure. This is essentially an affection of the aged excepting in its 
rectal form. The stools often contain mucus, blood, and scybala. The 
absolute diagnosis may be dependent on the effect of repeated high 
enemata. 

Actinomycosis. — ^Actinomycosis is characterized by a preliminary 
period of intestinal diarrhea with bloody passages, usually not painful, 
later by localized pain and tenderness, and tumor which involves the 
parietes, softens, reddens, and changes to a violet blue spreading from 
the centre to the periphery, held by Volkmann to be of diagnostic signifi- 
cance. Multiple fistulse ultimately form, healing in one direction and 
extending in others. The diagnosis is made by the microscope or is 
based upon the presence of other foci of the disease. 



THE APPENDIX. 

The appendix may be absent (rare). It is about three inches long 
but varies from half an inch to nine inches. It usually lies behind the 
cecum, exceptionally extraperitoneally and is coiled by its mesenteric 
attachment. Its free end varies in position in accordance with its length 
and the extent of its mesenteric attachment. It may be found as high 
as the gall-bladder or to the left of the midline. A process of non- 
inflammatory atrophy and partial or complete obliteration of the lumen of 
the appendix is frequently noted. 

Though the appendix is subject to tuberculous and malignant infiltra- 
tion, these conditions are not suspected until demonstrated by examination 
of specimens removed in the course of operation called for by associated 



540 THE ABDOMEN 

inflammation. Malignant tumors have usually been found only by 
microscopic examination of the removed organ; hence from the diag- 
nostic point of view acute and chronic inflammation of the appendix 
are mainly to be considered. 

Acute Appendicitis. — ^Acute appendicitis, essentially an affection of 
vigorous young men, common in childhood, rare in infancy and old 
age, is characterized by pain, tenderness, rigidity, vomiting, fever, and 
constipation. 

The pain, which at first may be general, umbilical, or epigastric, 
shortly becomes most marked in the right iliac fossa. It is usually 
continuous, with recurring exacerbations, and is aggravated by coughing, 
vomiting, deep breathing, or abdominal movements. 

Tenderness on palpation, the most important single localizing symp- 
tom, is best elicited by deep pressure at McBurney's point made with the 
tips of two fingers. When the anterior parietal peritoneum is inflamed, 
superficial tenderness is so marked that deep palpation is not possible. 

Pain and tenderness are both sometimes referred to the left iliac 
fossa, and are then suggestive of the pelvic seat of the tip of the appendix. 
This same position causes frequency of urination or pain at the end of 
the act. If the ureter be involved, the pain may radiate into the testicles 
or penis. 

An inflamed appendix lying posteriorly commonly occasions some 
rigidity of the psoas muscle characterized by slight flexion of the thigh 
and pain in efforts at extension. Pain is sometimes referred to the hip- 
joint or down the posterior inner surface of the thigh. 

Muscular rigidity involves particularly the lower half of the right 
rectus muscle, usually all the muscles of the inguinal region. A fixed 
contraction of a portion of the internal oblique or transversalis may 
closely simulate tumor. 

Nausea and vomiting are common accompaniments, sometimes initi- 
ating the attack, usually developing some hours after its beginning. Vom- 
iting is not likely to be persistent or recurring in the absence of diffuse 
general peritonitis. 

The bowels are usually constipated. There is commonly a preceding 
history of constipation, or of gastro-intestinal disturbance, occasionally 
of abdominal chill, contusion, or strain. 

There is fever, usually moderate, sometimes high, and leukocytosis. 
In uncomplicated cases the pulse is proportionate to the temperature. 

Inspection of the abdomen shows breathing of the thoracic type of 
about normal frequency, at times bulging in the right iliac fossa due to 
muscular contraction or local distention, and often moderate general 
tympany. 

The onset of symptoms affords no reliable index as to the subsequent 
course of the appendicitis. The sudden lessening of pain and tenderness 
may denote the relief of tension incident to gangrene or the internal 
rupture of an abscess. Rupture into the general peritoneal cavity is 
at times characterized by an immediate and shocking aggravation of 
pain. 



THE APPENDIX 541 

The subsidence of the local symptoms, associated with a weak, rapid 
pulse, is of grave prognostic import. 

The complications of acute appendicitis are: Local peritonitis, with 
or without abscess formation; intestinal obstruction; diffuse peritonitis; 
phlebitis, epecially pylephlebitis; subphrenic abscess; pyelitis, pyelo- 
nephritis, and cystitis. 

Local peritonitis is practically an invariable accompaniment of ap- 
pendicitis, and it is not until the symptoms of this condition develop 
i. e., fever, tenderness, and rigidity, that a diagnosis can be made. 

Abscess formation is characterized by a persistence or aggravation of 
the symptoms of local peritonitis together with those of septic absorption. 
Tenderness becomes more marked and more circumscribed, rigidity 
more pronounced, and if the abscess is placed anteriorly or in the pelvis, 
tumor may be felt either by external palpation or rectal examination. 

Abscess incident to suppuration of a postperitoneal gland or of the 
appendix behind the colon or to its outer side occasions tenderness best 
elicited by pressure in the loin. Pelvic abscess usually causes marked 
pain on urination. 

Appendicular abscess may follow subacute appendicitis, attended by 
symptoms so slightly marked that in the absence of a careful examination 
they are attributed to indigestion. Such an abscess, insidious in onset, 
of slow growth, and attended by moderate toxic symptoms, may closely 
simulate carcinoma, from which it may be impossible to distinguish it 
except by operation, though the size of the resultant tumor in the absence 
of obstructive symptoms and the gradual merging of its induration with 
the surrounding tissues would suggest inflammation rather than carcinoma. 

Intestinal obstruction, partial in its mildest form and incident to local 
inflammatory paresis, is a usual symptom of acute appendicitis, and is the 
cause of the constipation and local tympany, associated with demon- 
strable, but not exaggerated, peristalsis. 

Exceptionally from inflammatory adhesion the obstruction becomes 
absolute ; it then exhibits in addition to the tympany of local peritonitis 
the colicky pain, the exaggerated peristalsis, the recurring and persistent 
vomiting, the absolute constipation, and the toxemia characteristic of 
this condition when due to other causes. Acute or subacute and 
recurring obstruction is usually a late (weeks, months, years) sequel of 
appendicitis and is then due to strangulation beneath a band or kinking 
of the gut by adhesion. 

Diffuse peritonitis is the commonest immediate sequel of appendicitis if 
local abscess be excepted. It exhibits typical symptoms (see p. 478), and, 
when well-developed, may entirely obscure its original cause, the diagnosis 
of this being based upon the history of onset and possibly upon an 
intensification of pain and tenderness in the right iliac fossa. 

Phlebitis may be secondary to appendicitis, as it is to other forms 
of infection. It occurs generally during convalescence, and, when it 
attacks the mesenteric veins, is marked by diffuse pain and tenderness, 
moderate tympany, fever, and leukocytosis. In the case of the iliac or 
femoral vein, pain and edema of the leg and the detection of the swollen, 



542 THE ABDOMEN 

tender vein on palpation are diagnostic. When intra-abdominal veins 
are involved the diagnosis must be by exclusion, possibly confirmed by 
the detection of an inflamed peripheral vein. 

Pylephlebitis, the most serious manifestation of secondary vein in- 
fection, accompanied by suppuration of the liver, is a late (weeks) sequel 
of acute appendicitis, particularly of the insidious form. It is charac- 
terized by the symptoms of violent sepsis, and pain, tenderness, and 
swelling in the region of the liver. 

Subphrenic abscess, usually of the right side, and due to peritoneal 
extension, the infection exceptionally reaching the diaphragmatic region 
postperitoneally, is often complicated by a serous or purulent pleurisy. 
The symptoms are similar to those of suppurative pylephlebitis, but less 
markedly septic. 

Pleurisy, even in the absence of subphrenic abscess, is an occasional 
complication of appendicitis as it is of other septic processes. 

Pyelonephritis and cystitis are caused by extension of inflammation 
or rupture of an abscess into the pelvis of the kidney or the bladder, 
an exceptional ultimate result in intestino-urinary fistula. 

Septicemia and pyemia with their various expressions may be com- 
plications of infection of the appendix. 

Chronic Appendicitis .^Chronic appendicitis, usually consequent upon 
an acute or subacute attack, often developing in the absence of a history 
of such, may be manifested by recurrent acute attacks, with intervals 
of perfect health, or by a condition of chronic invalidism, with some 
symptoms referred to the right iliac fossa or with simply those of a chronic 
gastro-enteritis with toxic absorption. 

Localized pain and tenderness occurring with exacerbations usually 
incident to imprudence in diet attended by muscular rigidity and perhaps 
slight fever are sufficiently diagnostic of the recurrent or relapsing forms. 
The latent form, characterized mainly by a mild but inveterate toxemia, 
may be exceedingly difficult to diagnosticate. 

Chronic constipation, flatulence, distaste for food, and impaired 
stomach digestion, sometimes diarrhea, and pain which may be placed 
in any part of the abdomen or may exhibit radiations downward simu- 
lating sciatica, sacro-iliac disease, or coxalgia, are symptoms which may 
arise from many different conditions, all of which must be eliminated 
before a diagnosis of chronic appendicitis can be made. It is in this 
condition particularly that the Head sign — i. e., cutaneous hyperalgesia 
in the region immediately overlying the appendix — may be of service. 

A diagnosis formulated on the basis of the symptoms of a chronic 
intoxication, other sources of which have been eliminated by careful 
examination or treatment, is often corroborated by operation, but this 
should not be performed until the surgeon is willing to definitely state 
before operation his belief in his diagnosis. 

In this class of patients, always neurasthenic, a McBurney point 
tender to deep palpation can always be elicited, as could a tender spot 
on any other part of the abdomen toward which the attention had been 
directed by repeated and perhaps rough examination. 



THE APPENDIX 543 

The complications of chronic appendicitis are those incident to 
toxemia, and may be manifested in the form of neurasthenia, gastro- 
intestinal indigestion, albuminuria, neuralgia, neuritis, arthralgia, 
arthritis, or exanthemata. 

Of the abdominal complications, abscess, adhesions, and partial or 
complete obstruction and pylephlebitis and hepatic suppuration are those 
most frequently encountered. 

There are some non-surgical conditions which so closely simulate the 
local peritonitis of the right iliac fossa which is characteristic of appendi- 
citis that mistakes in diagnosis have been made and needless operations 
have been performed. 

1. The Invasion Enter algia of Typhoid Fever. — There may be severe 
pain in the right iliac fossa and pronounced tenderness. The tender- 
ness is not sharply localized, the muscular rigidity is not well marked, 
and the symptoms of local peritonitis are wanting. The characteristic 
prodromes of typhoid and particularly the leukopenia and the slow 
dicrotic pulse are suggestive as to the true nature of the affection. The 
enlarged spleen, rose spots, and the serum reaction do not appear 
sufficiently early (eighth day) to be helpful in differential diagnosis. 
After the first week the symptoms of a local peritonitis in the right 
iliac fossa may become pronounced and typical, and are then due to 
appendicitis or a deep ulcerative lesion of the ileum or colon. 

2. Referred pai7i, tenderness, and rigidity secondary to right-sided 
pleurisy or pneumonia. The tenderness is superficial and may be 
relieved by deep, broad pressure, the rigidity is not well marked, the local 
symptoms are suggestive rather than diagnostic, and the unduly rapid 
breathing should indicate the diagnosis even before the physical signs 
make this assured. Observation of such a case shows subsidence rather 
than aggravation of the signs in the right iliac fossa. 

3. Dysmenorrhea. — The pain and voluntary rigidity simulate appendi- 
citis mainly to the enthusiastic seeker for the disease. The patient 
usually makes the correct diagnosis, based on previous experience and 
knowledge of a cause for a more than usually severe attack. 

4. Ileocolitis incident to simple catarrh, ptomain poisoning, gout, 
uremia, rickets, tuberculosis, exanthematous skin lesions, and arthritis 
(Osier) may exhibit the pain of appendicitis but without its localization, 
nor are the other symptoms of local peritonitis present. The sudden 
cessation of diarrhea, the substitution of fixation for protective rigidity 
of the right rectus muscle, the increase in temperature and leukocytes 
and an aggravation of pain and tenderness in the right iliac fossa indicate 
a local peritonitis usually due to an associated appendicitis. 

5. Inflammation of the kidney or obstruction of its ducts exhibits most 
marked tenderness on deep pressure at the costovertebral angle with 
radiation of pain along the ureter and to the external genitals. Exami- 
nation of the urine is usually suggestive, and unmistakable symptoms of 
peritonitis in the right iliac fossa are absent. 

6. Inflammation or obstruction of the gall passages exhibits the symp- 
toms of a local peritonitis in the gall-bladder region, with evidences of 



544 THE ABDOMEN 

backing of bile if this be a complication. It occurs in the middle aged 
and is often a sequel to enteritis or typhoid fever. The differentiation 
between cholecystitis and appendicitis may be impossible with an inflamed 
appendix lying in the gall-bladder region. 

7. Inflammation of the right tube or ovary causes pain, tenderness, and 
rigidity at a point lower than that characteristic of the inflamed appendix; 
it is preceded by vaginal discharge and is diagnosticated by vaginal 
examination. The two conditions may be combined. 

8. Seminal vesiculitis at times causes an inflammation of the overlying 
peritoneum, and is then characterized by pain, tenderness, and rigidity 
located in the right iliac fossa. The seat of greatest tenderness is not 
over McBurney's point, the urine contains pus, there is a history of ure- 
thritis, and a rectal examination demonstrates the tender and enlarged 
vesicle. 

In children the symptoms of appendicitis are similar to those in 
the adult. The affection, however, seems more prone to follow slight 
traumatism, and the abdominal symptoms of a pleurisy or pneumonia 
are more likely to lead to error. 

Intussusception, strangulated hernia, beginning typhoid fever, peri- 
nephric abscess, pyelitis, inflammation of a retained testicle, and acute 
coxitis may exhibit symptoms sufficiently like those of acute appendicitis 
to lead to a mistaken diagnosis. 



THE ANUS AND RECTUM. 

Examination of the anus and rectum is best conducted in the knee- 
chest or the exaggerated lithotomy position, though the left lateral 
position is usually satisfactory. A careful inspection of the perianal 
skin is followed by palpation of the tissues about the anus. Thus may 
be detected not only skin inflammations, fistulous openings, and tumors, 
but by the tenderness and induration, abscesses and fistulous tracts. By 
drawing the buttocks aside and directing the patient to strain as in defe- 
cation, fissures, hemorrhoids, prolapse, and polyps are usually seen. 

Digital examination should always precede the introduction of an 
instrument. The finger should be covered by a thin, smooth rubber cot, 
and should be lubricated by an Irish-moss preparation; thus is the 
examination made less pairiful. When the anus is hypersensitive the 
examination may be preceded by a 20 per cent, lactate of eucaine solution 
applied by means of a cotton swab which is passed within the grip of the 
sphincter and allowed to remain for five minutes. The finger is intro- 
duced upward and forward until the sphincter (half an inch) is passed; 
it is then turned backward. 

Stricture, polyp, fissure, ulceration, foreign body, often the inner 
orifice of fistulae, perirectal abscess, infiltration, or tumor, can be detected 
by such an examination. 

The ocular examination of the rectum is best conducted by means of 
straight tubes. For examination of the anus when there is a sphincteric 



PLATE XV 111 

FIG. 1 




Dissection showing the Arrangement of the Anorectal Veins. (Otis,) 

An alcoholic preparation of the lower rectum opened lengthwise in the median line anteriorly, a 
portion of the raucous membrane and mucocutaneous tissue having been removed to expose the 
internal and external hernorrhoidal veins. 

X, x' . The lowermost plica transversalis recti, one of a series of ineffaceable transverse folds that are 
present in the rectum, with considerable variation as to their number and distinctness ia different 
individuals. a. The short and narrow anastomoses between the dilated portion of the internal 
hemorrhoidal veins above and the dilated portion of the external hemorrhoidal veins below, e. Dilated 
external hemorrhoidal veins, g. The sulcus or groove that encircles the anal orifice. Just above are 
to be seen the column* and lacunae of Morgagni. is. Internal sphincter, es. External sphincter. 



FIG. 2 




Longitudinal Section through the Rectal Outlet (Semidiagrammatic). (Otis.) 

1. Skin. 2. External sphincter. 3. Levator ani. 4. Longitudinal muscular fibers. 5. Circular 
muscular fibers terminating in the internal sphincter. 6. Internal hemorrhoidal veins in the sub- 
mucosa. 7. Mucous membrane. 8. One or more papillae often seen on the bases of the columns. 
9. The anorectal groove which is produced by the distention of the internal veins just above it and 
the external veins just below it. In the dead body, where the veins are empty, the groove will not 
be apparent. 10. Dilated portion of an external hemorrhoidal vein. 



THE ANUS AND RECTUM 545 

contraction of such obstinacy as to make gentle digital stretching of the 
anal opening inadequate, Kelly's short speculum and a headlight answer 
best. For deeper examination a proctoscopic tube carrying an electric 
light is to be preferred. For examinations of the upper part of the 
rectum and the beginning of the sigmoid, the distal end of the procto- 
scope should be provided with a window and an inflating bulb, allowing 
of colonic distention. The proctoscope should not be passed more deeply 
than four inches unguided by the eye. 

Congenital Malformation. — The anus may be narrowed, occluded, 
or absent, the rectum in the latter case ending in a blind pouch, often at 
a considerable distance from the perineal surface or communicating 
with the bladder, urethra, or vagina, or provided with an inadequate 
fistulous opening leading to the surface in the perineal region. The 
rectum may be absent, though the anus is normal. 

In cases of occlusion incident to absence of the anus or rectum, or 
both, the diagnostic problem has to do with the determination of the 
thickness of the occluding tissue. A thin partition will bulge during 
crying efforts and will give a sense of fluctuation to palpation when 
tense and one of yielding when relaxed. 

In the absence of these symptoms the position of the blind rectal pouch 
must be determined by perineal dissection, supplemented, if needful, by 
colostomy and the insertion of a sound into the descending colon. 

Narrowing of the anus or rectum is characterized by passage of ribbon- 
like feces. Unless extreme, it is usually undetected, constipation and the 
gradual dilatation of the bowel above being attributed to other causes. 
The infant anus should admit, under gentle pressure and without undue 
stretching, the well-lubricated rubber-covered little finger of the average 
sized man. 

The Skin Surrounding the Anus. — The perianal skin is especially 
subject to dermatitis, eczema, intertrigo, pruritus, folliculitis, marginal 
abscess, external thrombotic piles, and skin tabs. Also are found in 
this region the openings of perineal abscesses and fistulae, papillo- 
mata, herpetic, syphilitic, tuberculous, chancroidal, and epitheliomatous 
lesions. 

Dermatitis. — The thin pigmented folded skin about the anal orifice 
rich in hair follicles and sebaceous and sudoriferous glands affords a 
moist and sensitive surface for the action of irritants such as fermenting 
discharges from the anus or in women from the vagina. 

Burning pain, redness, often excoriation, and a serous or seropurulent 
discharge are characteristic features associated with prompt recovery on 
removal of cause. 

Eczema. — Eczema is distinguished from dermatitis mainly by its per- 
sistence; it is often associated with a like lesion elsewhere, particularly on 
the scrotum, and, as is true of a simple dermatitis, it exhibits a thickened 
cracked, excoriated, or fissured skin, moist with a chronic discharge, and 
attended by harassing burning and itching, accompanied by erosions and 
a distinct seropurulent discharge. Itching is usually distressingly per- 
sistent. 
35 



546 THE ABDOMEN 

Pruritus. — Pruritus has for its dominant symptom itching, usually 
worse at night, and unattended by skin changes other than the lesions of 
scratching, and nearly always a white, thickened skin about the anal 
margins. Its usual underlying cause is an anal or rectal lesion causing a 
slight discharge. Careful examination, however, often does not result 
in finding such a cause. 

Folliculitis. — This develops about the anal margins, often incident to 
chafing or the conditions which cause dermatitis, in the form of small pim- 
ples or boils, tender to pressure, healing after discharge, often persistently 
recurring, at times confluent, resembling a small carbuncle. Sometimes 
resulting in marginal fistulse. These lesions make walking and bodily 
activity painful, but do not interfere with defecation. Their superficial 
induration and acute course are characteristic. 

Marginal abscess due to folliculitis, a broken-down thrombus, or infec- 
tion from abrasion, is attended by tenderness and pain, usually slight, 
unless the abscess extend within the grip of the sphincter, when it is 
severe, is greatly aggravated by defecation, and is associated with con- 
stitutional symptoms of infection. Examination shows the tender, 
edematous inflammatory infiltration. Its rupture is followed by a per- 
sistent sinus or superficial fistula, which may have numerous openings; 
the tracts, however, remain just beneath the skin or mucous membrane. 
Their openings are exposed and they are readily followed if the skin 
folds about the anus are smoothed out by stretching. 

The onset of these abscesses is often so symptomless that the surgeon 
is not consulted until the annoying discharge and the resultant dermatitis 
make this seem advisable. Such an onset is suggestive of tuberculosis, 
as is extensive undermining of the skin. 

The distinction between thrombotic pile and a marginal abscess would 
be suggested by the sudden onset of the former. It should be made 
absolute by incision under local anesthesia. 

Thrombotic external hemorrhoids, due to venous rupture and blood 
extravasation, are characterized by a sudden perineal ache, often follow- 
ing defecation, urination, seminal emission, or muscular strain, and the 
rapid development (within the hour) of a hard, tender marginal tumor, 
which becomes edematous and remains tender and painful for several 
days. If the tumor lies within the grip of the sphincter the pain is 
severe and persistent and is greatly aggravated by defecation. 

The diagnosis, based upon the sudden onset of pain, is made by direct 
examination and the discovery of the tender swelling, which, if it be 
mucocutaneous, its usual position, shows dark blue through its thin 
covering. If the blood effusion be too deep to exhibit characteristic 
color, and be not seen for one or two days, when inflammatory reaction 
has developed, the diagnosis from abscess should be made by incision. 

Inflamed Skin Tabs. — Because of a varicose condition of the external 
hemorrhoidal venous plexus and consequent stretching of the over- 
lying skin, its natural radiating folds are exaggerated. An acute inflam- 
mation of one or more of these folds is characterized by an edematous, 
tender swelling and often some eversion of the mucous membrane* 



THE ANUS AND RECTUM 547 

These acutely inflamed tabs are exceedingly tender, and in the furrows 
between them there are often fissures or short superficial fistulse. Each 
acute attack is followed by a permanent enlargement. Even in the 
absence of a history of acute inflammatory attacks these tabs may 
become greatly enlarged, forming pendulous fringes about the anal 
aperture. The condition is usually secondary to a slight dermatitis due 
to irritating discharge. 

Fissure. — Fissure, an ulcer within the grip of the external sphincter, 
is an affection of the adult, occasionally seen in children. It is character- 
ized by severe defecation or post-defecation pain and blood-streaked feces, 
often by a few drops of blood squeezed out at the end of defecation. 
The pain may last for hours, due in this case, in part at least, to muscular 
spasm, and may be associated with painful, difficult urination. 

The diagnosis is made by direct examination, which reveals, first, a 
rigid sphincter, next a sentinel pile, i. e., a mucous or mucocutaneous 
hypertrophied tag projecting below the seat of the ulcer, finally a point of 
sensitiveness on external pressure. Usually on gentle introduction of the 
finger, if this be practicable, the induration of the ulcer is found in the 
posterior commissure and just within the aperture. The ulcer can be 
seen by gently stretching the buttocks apart, with the patient in the left 
lateral or knee-chest position. A satisfactory proctoscopic examination 
will often have to be preceded by 20 per cent, eucaine solution because 
of the associated severe spasm. A superficial ulcer placed within 
the grip of the sphincter does not necessarily exhibit the symptopis 
of fissure. 

Ischiorectal Abscess. — Ischiorectal abscess, secondary to trauma or 
rectal or anal abrasion, or exceptionally to the extension between the 
fibers of the sphincter, or through the levator of a submucous or a peri- 
rectal abscess, is characterized by the local and systemic symptoms of 
acute inflammation, both well marked. The pain is greatly aggravated 
by defecation. The tenderness and induration are elicited by a finger 
passed within the rectum for the purpose of making counterpressure 
against external palpation. The seat of the tender induration and its 
acute onset are sufficiently characteristic. Later, surface heat, redness, 
and edema develop. Free suppuration usually forms a burrowing cavity 
which, if undrained, communicates directly with the bowel. 

Deep pelvic abscess, placed either laterally above the levator muscle 
or postrectally, gives rise to symptoms of septic absorption. This condi- 
tion may be suspected in its early course if a history of high rectal trauma 
or ulceration or lesion of the vesicles and prostate is present. Digital 
examination may show the presence of a boggy swelling. 

Fistulous Openings. — Fistulous openings, consequent to abscess and 
often tuberculosis, are the commonest rectal affections for which patients 
seek relief. They are characterized by indurations indicating their 
general direction, best detected by combined rectal and perineal palpa- 
tion, and by the presence of one or several undermined or exuberantly 
granulating openings from which is discharged pus, 



548 THE ABDOMEN 

Fistula. — The tract is usually complete, i. e., leads from the mucus 
to the skin surface. In many cases it is external and incomplete, having 
only a skin opening (blind external fistula). In a small percentage of 
cases it is internal and incomplete (blind internal fistula), having only 
one or more mucous openings. 

The short superficial marginal fistula, if complete, opens into one of the 
sinuses of Morgagni or below it. The ischiorectal fistula usually opens 
within the grip of the sphincter, usually in the pocket of a sinus. It 
may have multiple orifices both into the gut and on the skin surface. 

Tuberculous fistula can be suspected from its absolute indolence, 
tendency to burrow and undermine, failure to show any reactive or heal- 
ing power under treatment, and, if the fistula be complete, the presence 
on the mucous membrane of a ragged, undermined ulcer. Fistula is 
rarely an isolated lesion of tuberculosis. 

Fig. 339 




The most common form of fistula in aiio; incident to marginal abscess. 

Fistulse originating in bone disease may open into the perineum or the 
rectum. The symptoms of the major malady and the depth and dura- 
tion of the sinuses are characteristic. 

Urinary fistula may be perineal, the urine burrowing backward to the 
anus, which may be completely surrounded by the suppurating tract. 

Diagnosis is formulated by tracing the perineal induration, by the 
escape of urine from the tract, and by a preceding history of urethral 
obstruction. Suppurating bartholinitis is an occasional cause of peri- 
anal fistula in women. 

In the median line, sometimes near the anus, usually over the coccyx 
or sacrum, lies the postanal fissure or dimple, which contains hair, 
sebaceous matter, and not infrequently forms a suppurating sinus. 

Dermoid cysts, developing in or near the middle line over the coccyx 
or the last sacral vertebra, may, after suppuration, leave a persistent 
discharging sinus which might be mistaken for one of rectal origin. The 
history of the preexisting, painless tumor and the finding of hair in the 
sinus or its discharge will establish the diagnosis. 

The course of fistulse may be traced by perineal palpation, by careful 
probing, by injection with peroxide of hydrogen under gentle pressure 



THE ANUS AND RECTUM 549 

and palpation for crepitation or by injection with methylene blue solu- 
tion, and following the stained sinuses by means of the probe, grooved 
director, and knife. 

When the fistulae are complete, i. e., have both skin and mucous 
membrane opening, the inner orifice can be felt by palpation and seen 
and probed through the proctoscope. Because of the winding course of 
many of these complete fistulse the passing of a probe from one orifice to 
another may be impossible. 

Papilloma. — Papillomata, or warts, about the anal margin are usually 
confluent and may exhibit extensive growth. They are seen especially 
in women in association with similar growths about the genitalia. They 
are neither indurated nor extensively ulcerated at their bases. 

Syphilis of the Anus and Perianal Region. — Exceptionally, this begins 
as a chancre, usually single, appearing in the form of an indolent, indu- 
rated crack at the anal margin rather than as a typical rounded sore, 
though the latter may develop. 

The diagnosis is suggested by the indolence of the affection and the 
development of bilateral polyganglionic inguinal enlargements. It can 
be made by the finding of the spirocheta or the subsequent progress 
of the case. 

During the secondary period mucous patches are common about 
the anus and are prone to ulcerate, forming painful fissures which from 
persistent recurring irritation may become deep and destructive ulcers 
or may be complicated by ischiorectal abscess. The condyloma latum, 
characterized by flat, raised, round, or oval patches of papillary over- 
growth, is a not unusual manifestation. 

Tertiary syphilis, except in the form of diffuse myositis paralyzing 
the anal sphincter, is rare. The perineum may, however, be riddled 
by fistulse, the result of breaking down gummata or infiltrations of the 
rectum. 

Chancroids of the anus exhibit the characteristics of these lesions 
on the genitals in that the lesion is acutely inflammatory, rapid in 
development, and multiple and progressively so from auto-inoculation 
of skin surfaces lying in contact. When they appear in the fissured 
form, from inoculation of cracks between the radial skin folds, they are 
likely to be indolent and persistent. 

Chancroids remain superficial and are complicated by buboes in the 
inguinal region. In the grip of the sphincter they exhibit the symptoms 
of fissure except that they are more rapid in development and are 
always associated with external lesions. Rectal chancroid represents 
an extension from the anus. 

Tuberculosis. — Tuberculosis may appear in the anal and perianal 
region in the form of a papillomatous growth, or a primary ulcer. 
Usually as a fistula, secondary to perianal or rectal abscess, in turn 
caused by tuberculous folliculitis near or in the pouches of Morgagni. 
The lesions are characterized by indolence, persistence, slow extension, 
moderate infiltration, and association with tuberculous lesion elsewhere; 
finally, by the discovery of the tubercle bacillus in scrapings. 



550 THE ABDOMEN 

Malignant tumors of the anus, anal epitheliomata, are rare. They 
may be either of the superficial type, spreading slowly (months), with 
typically indurated borders surrounding a chronic ulcer, which grad- 
ually deepens; or, when the malignant infiltration begins in the follicle, 
they may be characterized by hard, deep, densely indurated ulceration 
(months). Infiltration of the inguinal lymphatic glands occurs early. 
The diagnosis is suggested by the persistence of an ulcerating lesion 
which is not syphilitic. It is based upon the microscopic examination 
of a portion of the growth. 

The rectum, by which is meant the portion of the bowel extending 
from the third sacral vertebra to the anus, is the seat of fecal accumula- 
tion, hence is especially prone to inflammatory and ulcerating lesions. 

Inflammatory lesions of the rectum are characterized by mucus, pus, 
and blood; obstructive lesions by obstinate constipation, often varied 
by spurious diarrhea. There will be little pain until the anus or the 
perirectal tissues are involved. The surgical affections of the rectum 
are proctitis, hemorrhoids, prolapse, traumatism, foreign body and 
fecal impactions, ulceration and internal fistulse, tumors and stric- 
tures. 

Proctitis. — Acute catarrhal proctitis, which may be due to irritating 
fecal matter or enemata, is characterized by urgent desire to defecate, 
frequent repetitions of the act, with the passage of small quantities at 
a time, failure to obtain relief therefrom, and a sense of burning pain 
in the rectum, often associated with some difficulty in micturition. The 
fecal matter, if it be formed, will be coated with mucus and perhaps a 
little blood. The attack is characterized by its rapid onset and quick 
subsidence, usually hours or days. 

Dysenteric Proctitis. — Dysenteric proctitis is characterized by frequent 
painful passage of bloody mucus. The dysenteric lesions are likely 
to become deeply ulcerous, those of the amebic type of dysentery 
being characteristic because of their linear shape. 

Diphtheritic Proctitis. — Diphtheritic proctitis has been reported as 
a secondary condition. 

Gonorrheal Proctitis. — Gonorrheal proctitis is due to inoculation by 
unnatural practices, or, in the case of women, by discharges running 
backward. The symptoms are those of acute proctitis, of pain and 
burning in the rectal regipn, followed by small, frequent, painful stools, 
containing a small quantity of bloody mucus. 

Diagnosis is based on finding the gonococci in the discharge. 

Chronic Proctitis. — Chronic proctitis is a common accompaniment of 
chronic inflammation of the large bowel. The symptoms of the local 
infection are usually merged in those of the major disease, excepting 
that there may be a constant mucous discharge from the relaxed 
sphincter, associated with dermatitis of the surrounding thickened skin 
and marked itching. Or the affection may be associated with con- 
stipation and the passage of feces coated with mucus and blood. The 
condition is commonly complicated by hemorrhoids. There may be 
multiple mucous membrane erosions. 



THE ANUS AND RECTUM 551 

Internal Hemorrhoids. — Internal hemorrhoids are capillary or venous. 
Capillary hemorrhoids exhibit no symptoms other than bleeding, which 
is free, recurring, and persistent; they may complicate venous hemor- 
rhoids. The diagnosis is based upon the bleeding and upon proctoscopic 
examination, which shows one or more nevous-like patches which even 
the gentle passage of the instrument makes bleed. 

Venous hemorrhoids are evidenced by the sensation of a full rectum 
not relieved by the act of defecation, bleeding, and prolapse, the latter 
occurring at first only when the bowels are opened and readily reduced 
either spontaneously or by manual pressure; later the sphincter becomes 
relaxed and the prolapse may become constant or constantly recurring 
as a result of increased intra-abdominal tension. 

Often internal hemorrhoids give no symptom. The diagnosis is 
made by direct examination. AAHien the piles have not been throm- 
bosed and contain little connective tissue, they cannot be felt. If they 
are subject to prolapse this condition may be brought about by causing 
the patient to defecate, giving him an enema to accomplish this end if 
needful, or having him assume the position of defecation and bear 
down as though accomplishing the act while the protected finger which 
has been introduced into the rectum is withdrawn. A Sims or short 
cylindrical speculum will bring the hemorrhoidal tumors into view. 

When the prolapsed internal hemorrhoids are prevented from 
retracting or being forced back by the grip of the sphincter, they become 
greatly swollen and excessively painful. 

The external hemorrhoid, which is a subcutaneous blood clot, is some- 
times taken for an internal pile strangulated by the sphincter and violent 
painful and useless efforts are made to reduce it. They may look much 
alike, but there is no complete sulcus between the external pile and 
sphincter, and inspection shows it to be extrasphincteric. 

Prolapse. — Prolapse may involve the mucous membrane only or all 
the coats of the bowel. 

Mucous membrane prolapse, the commonest form, is usually observed 
in young children, as the result of recurring straining efforts such as 
are symptomatic of vesical calculus or dysentery, though it is common 
in the feeble and aged as an expression of muscular relaxation. It is 
of gradual development, and may involve a part or the entire circum- 
ference of the gut which projects for a distance of one or two inches, 
exhibiting an abnormally red and thick mucous membrane which is 
continuous with the circumanal skin, there being no sulcus between 
the two. 

The central aperture appears at the end of the projection and from 
it pass radiating folds. 

Complete prolapse, which may contain peritoneum and loops of small 
intestine, forms a thicker, larger tumor, usually more than two inches 
in length, curved backward in the male and forward in the female, and 
exhibiting a slit-like orifice. It is often an after-development of mucous 
prolapse, but exceptionally may develop suddenly as the result of a vio- 
lent strain. There is usually little pain in this affection, and reduction 



552 THE ABDOMEN 

is easy. Repeated inflammation may make it irreducible. If the 
exposed bowel becomes inflamed and eroded, defecation may be exceed- 
ingly painful. 

The distinction from a prolapsed intussusception is based upon the 
finding of a sulcus between the projecting mucous membrane and the 
anal margin, the skin and the mucous membrane not being continuous. 

Trauma of the Rectum. — Trauma of the rectum, noted most 
frequently in sexual perverts, may occur from the rough introduction 
of an injection pipe or, if there be preceding disease, from even the gentle 
passage of rectal bougies. If the wound be perforating, there may be 
little or no immediate bleeding or pain. Rectovesical fistula, perirectal 
abscess, pelvic cellulitis, or peritonitis follows in accordance with the 
depth and direction of the perforation. The diagnosis is made by 
direct examination. 

Foreign Bodies. — These may be introduced through the anus. Usually 
they have been swallowed, finally lodging in the rectal ampulla. Since 
this is devoid of sensibility, perirectal abscess, diffuse cellulitis, or peri- 
tonitis may develop without preceding local symptoms. 

Usually there are pain, tenesmus, the passage of mucus, often blood- 
stained, and a sense of fulness in the rectum. If the body is large, 
obstructive symptoms will develop, and are unrelieved by the act of 
defecation which in itself is usually painful. Urinary reflexes are at 
times marked. 

A small foreign body, such as a seed or fish-bone, lodged in one of 
the crypts of Morgagni may occasion a constant burning associated with 
distressing sphincterismus. 

Diagnosis is based upon digital and proctoscopic examination. 

Fecal Impaction. — Impacted masses of feces may remain in the rectal 
ampulla for weeks or months, there being no symptoms other than obsti- 
nate constipation alternating with diarrhea, and mucus and blood in 
the stools. A persistent or frequently recurring diarrhea, especially if 
characterized by small passages containing mucus and blood, should 
always suggest rectal examination. 

Ulceration of the Rectum.— Ulceration of the rectum may be trau- 
matic, dysenteric, dependent upon a blind internal or rectovesical fistula, 
carcinomatous, tuberculous, or syphilitic. 

Abrasions or erosions accompanying acute irritating catarrh or mild 
dysenteric attacks are characterized only by mucus and pus in the stool 
and symptoms of acute proctitis. Anal tenderness usually prevents a 
satisfactory proctoscopic examination, nor is this needful, since the 
symptoms are transitory. 

Traumatic ulceration, even though there be no definite history of 
injury, heals promptly or develops fistula. Dysenteric ulceration of 
the rectum is multiple and a minor feature of ulceration of the bowel 
higher up. 

Blind internal fistulse are particularly marked by pain, purulent, 
sometimes blood-stained discharge; exacerbations and remissions of 
inflammation, the remissions being accompanied by increased discharge 



THE ANUS AND RECTUM 553 

and the detection of induration on palpation, and by direct inspection 
and probing. Blind internal fistulse may have two openings, and, if well 
drained, may be difficult to find. 

Syphilitic Ulcers. — Syphilitic ulcers, very rarely chancrous, nearly 
always beginning as infiltrations or gummata of the tertiary disease, 
are characterized by the painless, symptomless development of one or 
many punched-out ulcers upon an infiltrated rectal wall. They are 
sometimes complicated by the formation of gummatous fistulse which 
may call attention to the rectum. Women are particularly subject to 
tertiary involvement of the rectum, which begins just within the grip 
of the internal sphincter. 

The diagnosis is usually not made until either abscess or fistula has 
developed, or by cicatricial contracture the rectum is so narrowed that 
partial obstruction is produced. It is then based upon the history 
of the case, the insidious onset, the extensive area of infiltration, or, if 
the affection be seen earlier, the nodosities of gummata and the typical 
punched-out ulcers. The distinction from malignant disease should be 
made by excision and microscopic examination of a portion of the 
ulcer. 

Tuberculous Ulcers.— Tuberculous ulcers, found in the lower part of 
the rectum, may begin as inflamed follicles which coalesce and break 
down, leaving undermined, slightly indurated ulcers, exhibiting soft, 
pallid granulations with bluish borders, and often a peripheral mucous 
membrane infiltration of minute tuberculous nodules. 

Malignant Ulcers. — Malignant ulcers are characterized by extensive, 
dense, peripheral infiltration, and friable, at times exuberant, granulations. 
The diagnosis is based upon the presence of the ulcer, and is corroborated 
or disproved by the result of microscopic examination of a portion of the 
ulcer. 

Stricture of the Rectum. — Strictures of the rectum are consequent to 
ulceration and cicatricial contraction. Ulcers which cause strictures are 
usually malignant, syphilitic, or tuberculous. Traumatic and dysen- 
teric strictures are rare and usually give a history which, associated with 
the absence of infiltration and the clearly outlined constricting fibroid 
tissue, is diagnostic. 

Stricture, when developed, is characterized by constipation which 
becomes progressively more obstinate, requiring for its relief not only 
laxatives and solvent enemata, but violent muscular efforts on the part 
of the patient, often assisted by digital manipulations where the narrow- 
ing is low down. This constipation is accompanied by dilatation above 
the point of narrowing, often by an accumulation of feces which can be 
felt through the thin abdominal wall, not infrequently by a spurious 
diarrhea representing an overflow of the more liquid parts of the feces 
mingled with mucus, pus, and blood, and accompanied by the symptoms 
of gastro-intestinal indigestion and ptomain absorption. The feces are 
broken, but not necessarily ribbon-like. 

When the stricture lies low there is usually an associated atony of the 
sphincters, allowing a constant or intermittent discharge of blood-stained 



554 THE ABDOMEN 

mucopus. Perineal fistulse are common complications. When the 
stricture is beyond the reach of the finger, the proctoscope should be used 
for its diagnosis. This, after having passed the sphincter, is introduced 
under the guidance of the eye until the point of narrowing is reached. 

Spasmodic stricture, due to chronic contracture of the internal and 
external sphincter, can generally be traced to some local inflammatory 
lesion. 

Malignant stricture is characterized by the deep, friable ulceration 
surrounded by its nodular, indurated wall, involving not more than two 
or three inches of the bowel in its long axis, usually its entire circumfer- 
ence. The diagnosis is made by microscopic examination. 

Syphilitic stricture exhibits a more extensive infiltration often with 
trifling and superficial ulceration, at times associated with perirectal 
abscess and multiple sinuses. It rarely appears as a single destructive, 
indurated ulcer. Such a stricture may form in the absence of preceding 
ulceration. 

The diagnosis is based upon the history of the case and the micro- 
scopic findings. The therapeutic test is usually of no avail, since the 
affection, when seen, has reached its cicatrizing stage. 

Tuberculous stricture is rare, since tuberculosis is essentially a slowly 
destructive process. The ulcer is soft, undermined, and destructive, 
and usually complicated by perineal fistulse. The diagnosis is based 
upon the finding of other tuberculous lesions and upon microscopic 
examination. 

Narrowing of the rectal lumen by the pressure of a perirectal tumor 
will cause obstruction and, from back pressure, a catarrhal inflamma- 
tion. The bloody, purulent discharge of ulcer will not be found, and 
a pelvic tumor of sufficient size to occlude the rectum may be felt. 

Tumors of the Rectum. — These may be benign or malignant. 

Polyp. — Polyp is the common benign tumor. It may have an adeno- 
matous, fibromatous, myxomatous, lipomatous, or lymphangiomatous 
basis. 

Polyp is common in children and is single or, at most, in small number. 
In the adult it is often single, but at times is amazingly multiple, the 
rectum being studded with hundreds of small tumors which may be 
rounded or pointed. 

' Bleeding and tenesmus are the only symptoms and both may be 
absent until a polyp prolapses sufficiently to be grasped by the sphincter. 
Often a palpable prolapse is the first symptom. Bleeding from the 
rectum of a child unattended by other symptoms is usually due to polyp. 

The diagnosis can usually be made by digital examination. This 
may deceive, however, since the polyp is readily pushed up by the ex- 
amining finger, and, moreover, if made up of mucous tissue, may exhibit 
very much the consistency of the surrounding rectal wall. By sweeping 
the finger around the circumference of the rectum after it has been intro- 
duced as far as possible and drawing it toward the anus the pedicle may 
usually be felt. 

The diagnosis is made absolutely by a proctoscopic examination which 



THE ANUS AND RECTUM 555 

shows the mass or masses usually pallid and watery in appearance. 
The fibrous polyp may be quite hard. 

The villous polyp (rare) exhibits a bright red, easily bleeding, warty 
surface, distinguished from malignant growth by the absence of the 
tendency to deep ulceration and induration about the base. It is an 
affection of the adult. 

Fibroma, enchondroma, and myoma have all been noted as non- 
pedicled growths from the rectal wall (rare). 

Cancer of the Rectum. — Cancer of the rectum, commonest in men past 
middle age, but also observed in early life, particularly in the soft or 
gelatinous form, is usually placed in the rectal ampulla just above the 
anus. It forms a deep friable ulcer, with irregular, nodulated, densely 
indurated borders, which ultimately become adherent to the surround- 
ing parts. The infiltration and cicatricial contracture not only eon- 
strict the lumen of the bowel, but lessen it in length. The area of 
narrowing is usually not more than one to three inches in width, except 
in the case of the soft or medullary cancer, when it may be as broad as 
that of tertiary s}^hilis. 

The diagnosis of malignant ulceration is suggested by the habitually 
recurring passage of small, offensive stools containing pus and blood. 
This is most marked in the early morning. At the time of first ex- 
amination, the ulcer is usually completely circumferential. There 
is obstinate constipation, difficulty and pain in moving the bowels, 
exhaustion following the act, and rapid deterioration in health. The 
diagnosis is made early by the character of the infiltrated ulcer and the 
microscopic examination of a portion of it. 

Sarcoma. — Sarcoma, an affection of middle age, begins as a sharply 
defined submucous nodule which grows rapidly, forming a soft rounded 
tumor with a clearly defined, non-indurated base. It ultimately ulcer- 
ates, bleeds, and obstructs. It is diagnosticated by rectal examination, 
excision, and microscopic examination. 

Perirectal Tumor. — Perirectal tumor may appear in the form of 
dermoid cyst, characterized only by obstructive symptoms and the 
detection of a mass either behind or in front of the rectum, sharply 
outlined. It is found mainly in women, and diagnosis is made by the 
finding of normal uterus and ovaries and the removal of the tumor. 
From the anterior surface of the sacrum and coccyx, lipoma, lymph- 
angioma, and teratoma develop as congenital tumors. Anterior spina 
bifida in the sacral region may by projection of its sac into the upper 
rectum produce the effect of a cyst. The diagnosis can be made by 
deep palpation or by aspiration. 

Papillary hypertrophies of the borders of the semilunar valves, 
characterized by pallid, w^art-like projections of their borders, are 
regarded as fertile sources of all the neuroses. The same may be said 
of catarrhal inflammation of cr\^ts or follicles made by these valves. 
The relation between cause and effect in both these conditions still 
remains to be demonstrated. 



CHAPTER XVII. 

THE LOWER EXTREMITY. 
THE FOOT AND ANKLE. 

The skin covering the dorsum of the foot is thin, freely movable, and 
overlies a loose subcutaneous fascia in which are many veins. The tough 
plantar skin, prone to callosities, is intimately connected with its dense 
fibro fatty subcutaneous fascia. 

The malleoli constitute the most conspicuous bony landmarks of the 
foot and ankle. Two fingers' breadth below the inner malleolus can 
be felt the sustentaculum tali, a finger's breadth in front of this bony 
point the head of the astragalus, an equal distance farther forward the 
tuberosity of the scaphoid, the most distinct bony projection of the 
inner border of the foot. 

A finger's breadth below and slightly in front of the tip of the external 
malleolus the peroneal tubercle or ridge can be felt, and three fingers' 
breadth in front of this the base of the fifth metatarsus, the most promi- 
nent bony point on the outer border of the foot. 

The weight of the body is supported by an elastic arch, the bases of 
which are the internal tuberosity of the calcaneum and the heads of the 
metatarsal bones. 

The tibiotarsal joint allows of flexion and extension through an angle 
of about 75 degrees. The midtarsal joints allow of adduction, abduc- 
tion, inversion, and eversion, with combinations. 

The swelling incident to joint effusion is early characterized by 
obliteration of the slight depression which is observed to the inner and 
outer side of the extensor tendons in front, and a similar fulness in the 
space between the tendo Achillis and the posterior malleolar surfaces. 

Deformities of the Foot. — These may be congenital or acquired. 
Such congenital deformities as acrodactylism, syndactylism, polydac- 
tylism, macrodactylism, absence of bony parts, and talipes varus are 
obvious on inspection. That the varus of the newly born, though 
usually acquired incident to intra-uterine pressure, may be primary is 
shown by the fact of its being hereditary. 

Acquired deformities incident to pressure, inflammation, or contracture, 
as affecting the toes commonly appear in the form of an over-riding 
usually of the second and fourth toes, troublesome only because of the 
incident skin maceration and the formation of corns at the points of 
pressure. 

Hammer Toe. — Hammer toe, involving particularly the second and 
the third toe, is marked by sharp flexion of the second phalanx upon the 



THE FOOT AND ANKLE 



557 



markedly extended first. Bursse underlying the corns forming over the 
point of pressure are prone to suppurate and involve the neighboring 
phalangeal joint. 

Fig. 340 




Outer hamstring tendon (biceps). 



Popliteal space. 



Line of joint. 

Head of fibula. 
Short saphenous vein. 



Inner and outer heads of gastroc- 
nemius muscle. 



Peroneus longus and brevis muscles 
covering the fibula. 



Tendo Achillis. 

Tip of external malleolus. 

Peroneal tubercle. 

Tuberosity of 5th metatarsal bone. 



Surface markings of the leg and ankle. (G. G. Davis.) 



Hallux Rigidus. — Hallux rigidus, evidenced by tenderness, swelling, 
and fixation of the metatarsophalangeal joint of the great toe, usually 
in a position of slight plantar flexion, is observed in young people as a 
part of the symptomatology of weak foot. 

Hallux Valgus. — Hallux valgus, or outward deviation of the great toe, 
usually incident to the wearing of improperly constructed shoes, excep- 
tionally due to gouty or rheumatic joint changes, may be so marked 
as to constitute a subluxation outward of the first phalanx. Over the 



558 



THE LOWER EXTREMITY 

Fig. 341 




Common deformity incident to wearing narrow 
Fig. 342 




Bilateral hallux valgus and bilateral bunion. Subluxation of first metatarsophalangeal 
joints. Repeated acute inflammation of right bunion. (Carnett.) 



THE FOOT AND ANKLE 



559" 



head of the usually enlarged metatarsus there develops a tender corn or 
bursa. The latter, called bunion, is prone to suppuration, which, because 
of the greatly thinned ligaments lying beneath, readily penetrates to the 
joint. 



Fig. 343 




Club feet secondary to infantile paralysis. Right talipes equinovarus. Heel elevated. Foot 
inverted. Callus and bursa formation over surface of weight bearing along outer border of 
foot. Left pes planus. Flattening of arch and lengthening of foot. Relaxation of ligamen- 
tous structures at knee shown by the hyperextension. (Willard.) 

Fig. 344 




Pes cavus. High arch and short foot (Carnett.) 

Hallux Varus. — Hallux varus is the term applied to an inward deviation 
of the great toe more pronounced than normal. 



560 THE LOWER EXTREMITY 

Club Foot. — This deformity, exceptionally congenital, usually acquired 
as the result of muscular paralysis and failure to counteract the pull of the 
sound muscles and the drop incident to the weight of the part, appears as 
an equinus (plantar flexion), calcaneus (dorsal flexion), varus (inversion), 
or valgus (e version), two or more of these forms being commonly com- 
bined. In their ultimate development these deformities are accompanied 
by both malformation and displacement of the bones of the foot. The 
congenital form usually appears as an equino varus. 

Flat and Hollow Foot. — Flat foot, or pes planus, often a natural 
formation and in itself implying no weakness, and hollow foot, or 
pes cavus, are more or less obvious departures from the ideal mould 
which are readily detected by inspection. 

Flat foot as an acquired condition, is often, but by no means always, 
a feature of painful foot. The same may be said of the high arched foot. 

Fig. 345 




Flat feet (bilateral pes planus). Obliteration of arches. Lengthening and eversion of feet. 
Prominent scaphoids and internal malleoli. Contractures of toes with secondary corns. Pain- 
less. Tires easily on walking. 

Affections of the Foot Characterized Mainly by Pain.— The pain 
incident to wounds, contusions, sprains, joint inflammations, gout, 
rheumatism, and the remote effects of traumatism is usually accom- 
panied by other symptoms or signs of the underlying cause, and a 
more or less characteristic history. 

Painful Foot. — Painful foot, observed in lax-fibered youths and young 
adults, is characterized by a ligamentous weakness sufficiently pronounced 
to make standing or walking at first irksome, later painful. The foot 
is tender and often cold and clammy. The pain is usually referred to the 
midtarsal joint. The movements of the foot are limited by associated 
muscular spasm, often accompanied by cramp of the foot and leg. As 
the ligaments yield, a distinct flattening takes place, the head of the 



THE FOOT AND ANKLE 561 

astragalus forming an obvious projection below the malleolus and in 
front of it. 

Pain is usually more pronounced before the development of marked 
deformity, the latter representing an adaptation which allows of con- 
siderable use without very grave discomfort. The walk is character- 
ized by slightly flexed knees and short steps, mainly on the heels with 
the toes widely turned out, the shoe soles being habitually worn down on 
the inner side. 

Arteriosclerotic Pain. — This, usually observed in the aged, at times 
in the young, is characterized by its severity and persistence. It may 
precede by months or years the development of senile gangrene. The 
diagnosis is based upon the associated local and general symptoms of 
arteriosclerosis and the exclusion of other adequate causes. 

Painful Heel. — Painful heel is characterized by tenderness on pressure, 
so great as to make walking diflBcult or even impracticable. It is often 
associated with bony outgrowth; at times sufficiently pronounced to be 
palpable, usually demonstrable only by the x-vsiYS. With such out- 
growths, or independent of them, a chronic bursitis may develop. 

Chronic inflammation of the plantar fascia, injury or abnormal growth 
of the epiphysis, or chronic inflammation of the bursa lying between the 
tendo iVchillis and the calcaneum, characterized by a hardness which 
simulates bone, may be the underlying cause of painful heel, the point 
of local tenderness indicating in each case the seat of lesion. 

Anterior Metatarsalgia. — Anterior metatarsalgia, or ^Morton's disease, 
is a term applied to pressure neuritis due to a distortion of the anterior 
transverse arch incident to the wearing of tight or narrow shoes, thus 
causing the heads of one or more metatarsals to bear unduly upon the sole 
of the shoe or to be crowded laterally together. The nerve pressure 
is often accentuated by the growth of a corn. The affection is char- 
acterized by severe pain usually beneath the head of the fourth meta- 
tarsal bone, brought on by walking or standing. This may be sudden 
and cramp-like in origin, or may be preceded by burning or discomfort. 
Rehef is afforded by removing the shoe and kneading the foot. 

Affections of the Skin of the Foot. — The skin of the foot is particu- 
larly subject to hyperidrosis and bromidrosis. 

Chilblain. — Chilblain, usually attributed to a frostbite, but often inde- 
pendent of this, occurring at any age, is characterized by a burning sensa- 
tion, often accompanied by redness and tenderness; most pronounced 
in cold weather and aggravated by external heat. The surface of the 
burning foot is often cold and wet. 

Erythema Intertrigo. — ^This appears as a macerated hyperemic area 
incident to chafing. It may lead to ulceration, papillary outgrowth, or 
eczema. 

Erythema Multiforme. — Erythema multiforme may in its nodular form 
develop on the dorsum of the foot and simulate the swelling due to a 
bruise or the sting of an insect. It occurs in the spring and fah, attacks 
young people, usually exhibits multiple lesions, but is characterized by 
neither the pain nor tenderness of traumatism. 
36 



562 



THE LOWER EXTREMITY 



Urticaria is characterized as elsewhere by rapid appearance and dis 
appearance of burning wheals. It may be due to local irritation or 

may be incident to diet or medica- 
FiG. 346 tion. Angioneurotic edema, called 

giant urticaria, is characterized 
by a red, burning swelling which 
may involve the whole foot. It 
more commonly appears as a cir- 
cumscribed edematous area. 

Lymphedema, involving the whole 
of the foot, is usually secondary 
to recurring erysipelatous inflam- 
mation or to the obstruction of the 
lymphatic vessels from other cause. 
It is characterized by a brawny 
infiltration differing widely from 
the soft, pitting edema incident to 
bloodvessel insufficiency. 

Eczema.— Eczema of the feet, 
affecting by preference the sole, 
is usually marked by a vesicular 
eruption which becomes scaly or 
crusted, and is attended by par- 
oxysmal attacks of severe itching. 
When it is complicated by fissures 
it may constitute a distinct dis- 
ability. It is usually associated 
with gouty or rheumatic diathesis 
and with gastro-intestinal disturb- 
ances. It is likely to be symmet- 
rical and seasonal. 

Dermatitis. — Dermatitis is usu- 
ally incident to an infected abra- 
sion, and presents the features 
common to this condition else- 
where. It may be of such 
devitalizing severity as to cause 
gangrene of the skin, which sub- 
sequently invades the deeper tis- 
sues. This is particularly noted 
in diabetes and nephritis. 
Erysipelas exhibits its characteristic features. Erysipeloid is also 
observed on the toes. 

Diffuse phlegmon appears in its typical form following wound. 
Keratosis. — Keratosis, appearing in the form of a circumscribed, 
yellowish patch of cornification, is sometimes the predecessor of epi- 
thelioma on the feet. 




Keratosis plantaris following chronic eczema. 
(Hartzell.) 



THE FOOT AND ANKLE 563 

Plantar keratosis, or skin thickening, particularly at the expense of the 
corneous layer, is normal at points of pressure. It may occur, however, 
in the absence of pressure, as a congenital perversion of growth, or as an 
expression of a central neurosis. It may involve the whole sole, may 
appear in disseminated patches, or in the form of hard, shot-like bodies 
which can be dug out from their beds. It is sometimes associated with 
capillary dilatations, particularly in those subject to chilblains. 

Corns and warts are obvious to inspection. 

The skin sarcomas exhibit the features which characterize them in 
other parts of the body. 

Ulcerating and Gangrenous Skin Lesions. — Any of the skin lesions may 
become ulcerative or gangrenous, incident to virulent infection, con- 
tinued irritation, or lack of tissue resistance, singly or combined. The 
deep and destructive ulcers, if those secondary to S}^hilitic infiltration 
and neoplasm be excepted, begin as skin lesions. The same is true of 
gangrene except in its angiosclerotic or angioneurotic type. 

Ingrowing Toe Nail. — This, usually observed at the outer side of the 
great toe nail, appears in the form of a swollen, extremely tender nail 
fold, discharging usually from exuberant granulations a bloody pus. It 
may be the starting point of cellulitis or gangrene. 

Gummatous Ulcer. — Gummatous ulcer begins as an infiltration, which 
shortly (weeks) softens and discharges characteristic pus through a 
central round, punched-out opening. A suggestive history and evidences 
of other lesions are usually to be found. 

Lupus in either its superficial or deep form presents characteristic 
symptoms. 

Perforating ulcer of the foot, commonly observed in middle-aged or 
elderly men who are suffering from arteriosclerosis, lesion of the spinal 
cord or peripheral nerves, chronic nephritis, or diabetes mellitus, is 
characterized in its beginning by a callosity at a point of pressure, usually 
to the inner or outer side of the sole beneath the heads of the metatarsals, 
followed by ulceration beneath this cornified layer with slowly progressive 
destruction of the deeper tissues. The diagnosis is based upon the pain- 
less persistence of the lesion and its tendency toward deep rather than 
peripheral extension. 

Mycetoma, cr Madura Foot. — ^Mycetoma, or Madura foot, usually an 
infection of the tropics, exceptionally observed in the temperate zone, 
and affecting adults who walk barefooted, is characterized in its beginning 
by nodulation of the skin of the sole following traumatism or abscess. 
The nodule slowly extends both peripherally and in depth and becomes 
riddled with sinuses. Diagnosis is based upon the multiple sinuses, the 
enormous chronic thickening, particularly marked about the sole, and 
essentially by the finding in the pus of the yellowish or blackish granules 
which contain the Streptothrix madurse. 

Gangrene of the Foot. — Gangrene of the foot, when due to arterio- 
sclerosis, is often preceded by harassing pain. The starting point is 
usually a dermal trauma or ulceration. It is characterized by a 
mummification incident to the gradual obliteration of blood supply. 



564 THE LOWER EXTREMITY 

The moist gangrene due to the sudden circulatory obstruction, which 
may be local, incident to destruction or overwhelming infection, or may 
involve the main vessels of supply (trauma, thrombus, embolus), is char- 
acterized by putrid sloughing and profound toxemia. When it occurs 
as a complication of lesions in themselves trifling, angiosclerosis with a 
complicating diabetes or nephritis is usually present. The diagnosis of 
gangrene is obvious. 

Traumatic Affections of the Foot and Ankle. — Aside from wounds, 
the usual injuries of the foot and ankle are contusions or sprains. Un- 
usual swelling, unduly prolonged pain, disability, and localized tenderness 
to deep pressure should suggest fracture. 

Dislocations in the absence of complicating lesions are comparatively 
rare. 

Contusion. — Contusions of the sole of the foot are often attended with 
severe pain and marked tenderness. Marked aggravation of these 
symptoms, after three days of rest, is usually indicative of suppuration. 
Local heat, leukocytosis, and fever are corroborative signs. 

Persistent deep tenderness and disability after contusion are suggestive 
of fracture and call for the use of the ic-rays. 

Sprain. — Sprain of any joint of the foot is possible and is characterized 
by local swelling and pain, aggravated by motion. If these symptoms 
are unduly severe and persistent, bone injury should be excluded by the 
a:^-rays. 

Strain of the Ankle-joint.- — This is usually due to forced inversion and 
inward rotation, exceptionally to eversion and outward rotaton. In the 
latter case it is often complicated by fracture of the inner malleolus, 
the bone yielding rather than the exceptionally strong inner ligaments. 
Sprain is manifested by pain, tenderness, usually located below and in 
front of the malleolus, and swelling due first to blood effusion, later to 
inflammatory reaction. 

Convalescence from simple sprain should be early and complete. 
When there remain persistent pain, disability, and tenderness in spite 
of treatment appropriate to sprain, this in itself is suggestive of compli- 
cating fracture or intra-articular traumatism. 

Fractures of the Bones of the Foot and Ankle. — Fracture of the meta- 
tarsals and phalanges exhibits, in addition to the symptoms of sprain, 
crepitus and unnatural mobility. Eliciting these last two symptoms 
in the case of the metatarsals may be difficult or impossible, the diag- 
nosis being then suggested by the persistent sharply localized tenderness 
to deep pressure or to sudden thrusting of the corresponding toe backward 
and demonstration by the ^-rays. 

The proximal end of the fifth metatarsal may be fractured in running 
or jumping. Usually neither crepitus nor preternatural mobility can 
be elicited. Pain not disabling at first but increasing daily in severity 
and sharply localized tenderness being the only symptoms. 

The midmetatarsals of heavy persons or those carrying weighty 
burdens are at times broken by a slip or twist occurring at that period 
of the step when the weight is thrown on the forepart of the foot. 



THE FOOT AND ANKLE 565 

Moderate pain which persists and grows worse, dorsal swelling, with 
late ecchymosis (hours, days), and persistent localized tenderness are 
the usual symptoms. This is, at times, the mechanism of the painful 
and disabled foot observed in soldiers after long marches » 

Luxation of the metatarsals and phalanges is usually obvious to 
inspection and palpation. 

Fracture of the tarsal scaphoid, usually the result of a fall from a 
height on the toes, is characterized by pain, localized tenderness, often 
crepitus. Deformity is masked by swelling. If the scaphoid be dis- 
placed, it can be readily felt. 

Diagnosis is made by the ic-rays. 

Fracture of the Astragalus. — This is usually due to falling from a 
height and alighting on the feet. The fracture may be simple, running 
through the neck and breaking the bone into two parts, with or without 
forward displacement of the anterior fragment. It is usually commin- 
uted, representing a crush, and is further complicated by a break of the 
OS calcis. 

Severe pain, absolute crippling, possibly crepitus, and flattening of the 
foot may suggest a diagnosis. Swelling is so great, however, that the 
ic-rays are usually needful. Pain and disability are out of proportion to 
that customarily observed in sprain, nor is the tenderness so definitely 
and superficially placed. 

Fracture of the Calcaneum. — The os calcis may be broken in its 
sustentacular portion or through any part of the body or tuberosity. 

Fig. 3471 




Instance of the "os trigonum" of the astragalus existing as a separate ossicle, in a male, 
aged twenty-three years. Its appearance has been mistaken for fracture, which was sug- 
gested at first in this case, as an injury was followed by pain and local tenderness at this point, 
but a radiograph of the opposite ankle showed same appearance and excluded fracture. 

1 Figs. 347 to 353. Fractiires involving the bones of the tarsus. Outline drawings from radio- 
graphs by Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; patients 
referred by or from serAnces of Drs. White and Carnett, and from dispensaries. 



566 THE LOWER EXTREMITY 

Fig. 348 Fig. 349 




Fig. 350 



Fig. 351 





Figs. 348, 349, and 350. — Unusual injuries in regions of both ankles of an adult male, resulting 
from fall from telegraph pole, landing on both feet. Fracture of posterior and outer part of articular 
surface of tibia in each ankle. In addition, scaphoid broken in left tarsus; fracture astragalus and 
compound dislocation ankle right side. Latter was reduced at time, and radiographs made several 
weeks later, and after union in fractures. Fig. 348, anteroposterior view of left ankle, shows forward 
end of tibial fragment only. Fig. 349, lateral view of same, indicates seat of latter fracture and shows 
crush of scaphoid. Fig. 350, anteroposterior view right ankle, shows fracture of entire outer margin 
of articular surface of tibia and slight crushing of astragalus. (Neither shown in lateral view, which 
is omitted.) 

Fig. 351,— Oblique fracture of external malleolus of fibula and crush of scaphoid, in an adult 
male. Former easily diagnosticated clinically, but tarsal injury not identified, although a fracture 
somewhere in the tarsus was suspected. 



Fig. 352 




Fissured fracture of os calcis, without displacement, in a male, aged thirty-eight years. Line 
is in front of sustentaculum and attachments of calcaneoscaphoid ligament, and more anterior 
than usual. Clinical diagnosis of fracture difficult in such a case, and not made in this instance, 
injury having been regarded as a sprain of ankle, but patient was referred for usual routine x-ray 
examination. 

Fig. 353 




Comminuted fracture of os calcis in adult male. Arches of both bone and foot broken 
down, implying considerable laceration of ligaments. Injury represents unusual amount of 
violence. Fracture is accompanied by a disturbance in relations of tarsal bones suggestive 
of a subastragaloid dislocation. Clinical diagnosis not exceptionally difficult, but x-ray diagnosis 
easier, more certain, and more humane. Oval body under calcaneocuboid joint probably not a 
fragment of bone, but an ossified sesamoid often found here (in tendon of peroneus longus) and 
appearance in radiograph sometimes mistaken for fracture. 



568 



THE LOWER EXTREMITY 



Fracture of the sustentaculum has been characterized by sinking of the 
arch and simulation of the valgus deformity of Pott's fracture. Often 
the injury is expressed in the form of an extensive comminution. 

When the tuberosity is broken there may be marked separation, 
owing to the pull of the tendo Achillis, making the diagnosis easy. In 
the absence of such separation, flattening of the longitudinal arch, 
swelling about the heel, deep tenderness, and pronounced disability 
suggest a diagnosis which should be corroborated by the x-rays. 



Fig. 354 



Fig. 355 



Fig. 356 





Pott's fracture. (Hoffa.) 



Exaggerated deformity in Pott's 
fracture. (Park.) 



Deformity following Pott's fracture. 
Eversion of foot. A not vmcommon sequel 
to imperfect reduction. Serous effusion 
in ankle-joint. 



Potfs fracture, due to forcible eversion and abduction, is character- 
ized by a tear of the internal lateral ligament, or, if this be sufficiently 
strong, avulsion of the tip of the internal malleolus, and a fracture either 
at the base of the external malleolus, a short distance above this point, 
or, if the fall be such as to forcibly abduct the front of the foot, the break 
may be oblique and at a much higher level. The tibiofibular ligament 
is ruptured or avulses a fragment of the tibia, and the astragalus is dis- 
placed outward, or it may be jammed upward between the two leg bones 
if they are widely separated or the outer articular surface of the tibia 
is split off. 



THE FOOT AND ANKLE 



569 



Fracture of a single malleolus may be attended by but moderate im- 
mediate disability and no deformity. The only sign of fracture may be 
persistent, deep tenderness at the seat of break, associated with some 
joint effusion. 

Supramalleolar fractures, commonly due to jarring weight of the body, 
as from a false step, associated with a twist of the foot, usually abduction, 
is likely to be comminuted and extremely irregular. Aside from crepitus, 
preternatural mobility, great pain, and rapid joint swelling, there is no 
means of accurately determining the amount of injury and joint displace- 
ment aside from the a;-rays. The foot may be displaced in any direction. 

Separation of the lower epiphysis of the tibia, more frequent than that 
of its upper epiphysis, usually combined with fracture of the fibula and 
often with a chipping off of the outer tibial articular margin, is caused 
by an ankle twist (eversion), and exhibits the characteristics of fracture. 
It is suggested by the seat of the transverse break, by its age incidence 
(before eighteen), the absence of intra-articular blood effusion, and par- 
ticularly by the x-tsljs. The foot and the malleoli are usually displaced 



Fig. 3571 



Fig. 358 





Figs. 357 and 358. — Fracture of malleolus of fibula. A frequent type in which the line of fracture 
extends longitudinally from above do-miward and behind forward, and down to end of bone. As 
a rule, it shows in the lateral \-iew only (Fig. 358), as there is seldom lateral displacement. Clinical 
diagnosis often difficult, no deformity, and preternatural mobility and crepitus not obtainable in 
many instances. Fracture frequently overlooked, or diagnosis made only by x-rays. (Adult 
male, aged thirty-six years.) 



1 Figs. 357 to 370. Fractures of the bones of the leg at or near the ankle. Outline drawings 
from radiographs by Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; 
patients referred by or from services of Drs. White, Martin, Frazier, and Carnett, and private cases 
of Dr. Pancoast. 



570 



THE LOWER EXTREMITY 



Fig. 359 



Fig. 360 





Fig. 359. — Another very common type of fracture of lower end of fibula, due to inversion. In 
this instance the break shows in the anteroposterior view only. Patient, an adult male, could 
walk, and a definite clinical diagnosis of fracture could not be made, although suspected from pain 
on manipulation and local tenderness. 

Fig. 360. — Fracture both malleoli, in adult male, resulting from a jump from the top of a freight 
car. Fibular fracture at extreme tip. Both show in anteroposterior view only. Clinical diag- 
nosis not difficult. 

Fig. 361 




Fracture of lower edge of inner malleolus of tibia, in male, aged thirty-three years. Important 
because of possibility of rupture of external lateral ligament instead of fracture of fibula. Shows 
in anteroposterior view only. 



THE FOOT AND ANKLE 

FrG. 362 Fig. 3G3 



571 





Figs. 362 and 363. — Fracture both bones; tibia, inner malleolus, and posterior portion of articular 
margin; fibula, shaft at lower and middle fourths. Adult male. Anteroposterior view, Fig. 362, 
shows slight outward displacement of foot and fibular fragments not in apposition, but does not 
show posterior tibial fracture. Lateral view, Fig. 363, shows almost complete posterior disloca- 
tion at ankle. 



backward and outward with an obvious change in the relation of the 
malleoh to the long axis of the bones. 

Luxation of the Foot and Ankle. — Luxation of the digits and the meta- 
tarsal bones exhibits characteristic deformity and disability. It is 
usually due to direct trauma, and is often complicated by destructive 
lesions of the bones and soft parts. 

The displaced scaphoid in the absence of great swelling is easily 
recognized as such. 

Suhastragaloid dislocations may be in any direction. The relation 
of the malleoli to the astragalus is not disturbed, but the foot is thrust 
forward, backward, inward, or outward, and is fixed in its position; 
characteristic deformity in the absence of great swelling can be detected. 
This injury is often complicated by fracture, and a complete diagnosis 
cannot be made without the :c-rays. 

The astragalus may be driven from its bed between the os calcis, sca- 
phoid, tibia, and fibula, forward or backward, or may be rotated. The 
outward and forward displacement is the usual one, resulting in inward 
rotation of the foot w^ith the displaced bone readily palpable. 



572 



THE LOWER EXTREMITY 

Fig. 364 




Fracture nf both bones; fibula longitudinal through lower fifth; tibia, posterior margin of articular 
portion. Male, aged twenty-three years. Lateral view. Neither fracture is shown in the antero- 
posterior view. Diagnosis of tibial fracture difiicult clinically. 



Tihiotarsal Dislocation. — The foot may be displaced in any direction, 
usually outward and forward, with a complicating fracture. 

Backward dislocation is characterized by shortening of the anterior 
part of the foot, lengthening of the heel, prominence of the lower articular 
surface of the tibia over the instep where its sharp anterior rim may be 
felt, unless the swelling be excessive, and tense prominence of the tendons 
of the back of the ankle, unless the leg is shortened by a complicating 
fracture of the tibia. 

Associated malleolar fracture with great swelling and tenderness, 
may so obscure diagnosis as to make the x-rays or examination under 
ether needful. 

Outward and inward luxations, characterized by obvious deformity, 
are necessarily complicated by malleolar fracture. 

Upward luxation, in which the astragalus is driven between the tibia 
and fibula results in fixed foot with an apparent depression of the malleoli, 
almost to the level of the sole, and a lateral separation so pronounced as 
to be obvious to inspection and mensuration. 

Luxation of the Tendons. — Luxation of the tendons, usually of the 
peronei (rare) incident to violent muscular action, is characterized by 
severe pain, pronounced disability, local tenderness, and palpation of 
the displaced tendons, which usually can be snapped back into place. 



Fig. 365 



THE FOOT AND ANKLE 

Fig. 366 



573 




Figs. 365 and 366. — Epiphyseal separation of lower end of tibia with posterior displacement of 
epiphysis, carrying with it a fragment of posterior portion of diaphysis. Patient, a boy about 
sixteen years of age, caught his foot on the top bar when jumping a hurdle. Clinical diagnosis of 
exact nature of injury difficult, but a correct diagnosis and accurate reduction were essential. 
Anteroposterior view, Fig. 365, gives practically no information in this instance. Fig. 366, lateral 
view. 

Fig. 367 




Longitudinal fracture of lower end of tibia, with separation of anterior portion of bone which 
is displaced relatively forward with foot. Injury resulted from patient, a physician, being thrown 
from his carriage. Exact mechanism not known, as there were numerous other injuries. Clinical 
diagnosis of exact nature of injury difficult. Lateral view. 



574 



THE LOWER EXTREMITY 
Fig. 368 




Longitudinal fracture of the posterior aspect of the tibia extending downward to about middle of 
lower articular surface. Patient an adult male. Injury caused by wheel of an automobile passing 
over the part. No displacement. This fracture could not be diagnosticated clinically, although 
one was suspected, mainly because of inability of patient to walk on foot. Anteroposterior view 
shows no indication of a fracture. (Lateral view.) 



Rupture of the Tendons. — Rupture of the tendons, usually the tendo 
Achillis, frequently incomplete, is characterized by pain, partial or 
complete disability, local tenderness, and the detection of a break in 
continuity on palpation. This gap becomes promptly filled with blood, 
hence firm pressure may be needed to detect its presence. 

Tenosynovitis. — ^Tenosynovitis, or peritendinitis, in the region of the 
ankle-joint, commonest about the tendo Achillis, often affecting the 
sheaths of the peronei and the tibialis anticus and digital tendons, usually 
due to prolonged and unwonted use, at times a local expression of infec- 
tion, particularly that incident to gonorrhea or rheumatism, is character- 
ized by pain on movement, tenderness and swelling along the course of 
the tendon, and often fine crepitation. 

The tuberculous form, commonly secondary to bone or joint involve- 
ment, is characterized by insidious onset, slow progression, and a 
fluctuating, often loculated and crepitating swelling along the course 
of the tendon sheaths. In the tuberculous ulcerative form there is 
soft infiltration and abscess formation. 

Retrocalcaneal Bursitis. — Retrocalcaneal bursitis, or inflammation of 
the bursa between the os calcis itself and the tendo Achillis, commonly 
due to excessive use or a local expression of general infection, particularly 
gonorrheal rheumatism, is expressed by pain increased on motion, and 
tenderness and swelling, best elicited by pressure to either side of the 
tendo Achillis just above its insertion into the os calcis. The swelling 



THE FOOT AND ANKLE 

Fig. 369 Fig. 370 



575 





Figs. 369 and 370. — Compound comniinuted fracture of both bones at ankle, in a male, aged 
thirty-four years, resulting from direct violence — crush by a car wheel. (Other leg similarly broken 
higher up.) Clinical diagnosis of exact nature of injury difficult. Lateral view, Fig. 370, shows 
in addition a posterior luxation of ankle and foot with the lower fibular and lower and posterior 
tibial fragments, complete reduction of which could not be accomplished. 



is usually hard, nor is fluctuation readily demonstrable. The acute 
affection may become chronic. 

Inflammation affecting the bursa on the lower surface of the os calcis 
may be secondary to trauma, an evidence of fissured fracture or a local 
manifestation of constitutional infection. It is not infrequently accom- 
panied by periosteal outgrowth in the form of a spur. The diagnosis 
is suggested by the a;-rays, but must often be tentatively made by 
exclusion. 

Inflammation of the Joints and Bones of the Foot and Ankle. — 
Acute Arthritis. — Acute arthritis, commonest in the ankle-joint, if trauma 
and direct infection be excluded as causes, is usually incident to systemic 
infection, particularly that due to rheumatism and the gonococcus. 
Any of the infections may, however, be expressed in the joints of the foot. 
The symptoms are those of arthritis, namely, pain aggravated by motion 



576 THE LOWER EXTREMITY 

involving the joint, tenderness and swelling about the joint, limitation 
of motion, and, in the case of pyogenic infection, constitutional symp- 
toms. 

Acute Arthritis of the Metatarsophalangeal Joint. — Suppurative arthri- 
tis of this joint is usually secondary to an infected bunion. It is 
characterized by pain, swelling, and disability out of proportion to the 
original lesion and wide of it, by the rapid (days) formation of fistulse 
leading into the interior of the joint and by extension of pus beneath the 
deep fascia of the sole. There is local tenderness, edema of the dorsum 
of the foot, and a tendency to point between the great toe and the one 
lying next to it. 

Gout particularly manifests itself in the metatarsophalangeal joint 
of the great toe. It is marked by the sudden onset of the local symp- 
toms of a violent inflammation without adequate cause or correspond- 
ing constitutional symptoms. A similar inflammation of the joint, but 
one less violent in onset and slower in subsidence, follows tonsillitis 
and other forms of infection localized elsewhere. As in other parts 
of the body, the gouty toe has a tendency to exhibit chalky deposits 
with final degeneration and ulceration. 

The red, edematous, painful, and exquisitely tender swelling of 
acute gout closely simulates a pyogenic infection. It often follows 
slight trauma. The inadequacy of the cause, the absence of marked 
constitutional symptoms, the limitation of the inflammation to the peri- 
articular structures, and the history of the case are usually sufficiently 
characteristic. 

Acute arthritis of the tarsal and metatarsal joints, in its suppurative 
form usually secondary to infected wounds or suppuration of the soft 
parts, is characterized by the seat of swelling and tenderness, rapid and 
multiple fistulization, and the tendency to spread along the tendon 
sheaths of the leg. 

The tarsal and tarsometatarsal joints are subject to both gonococcal 
and rheumatic inflammation of crippling severity. 

Acute arthritis of the ankle-joint, characterized by pain, fixation in 
slight plantar flexion, swelling, and tenderness most marked to either 
side of the extensor tendons anteriorly and between the tendo Achillis 
and the malleoli posteriorly, may develop in the serous, fibrinous, or 
suppurative form. The diagnosis of the causative lesion is dependent 
upon the recognition of the systemic infection, usually gonorrhea or 
rheumatism. 

The gonococcal arthritis, except in its ephemeral serous form, is 
characterized by an especial intensity and persistence of pain, an early 
involvement of tendon sheaths and a tendency toward ankylosis. 
The grippal, exanthematous, typhoidal, and pneumococcal infections 
are in themselves not characteristic. 

The suppurative arthritis incident to infected wound, osteomyelitis, 
suppurating tenosynovitis is characterized by the rapid onset and pro- 
gression of both the local and general symptoms of sepsis. 

Suppuration complicating pyemia does not materially add to the 



THE FOOT AND ANKLE 577 

severity of the constitutional symptoms, nor are the local signs as 
pronounced as they would be from a traumatic pyogenic infection. 

Chronic Arthritis. — Chronic arthritis of the joints of the foot and ankle, 
when beginning insidiously is usually tuberculous. It may be post- 
traumatic or may follow any of the acute forms of infection. When no 
other cause can be assigned, it is termed rheumatic. 

When accompanied with deformity out of all proportion to the pain 
and disability it is usually tabetic. 

Post-traumatic arthritis usually incident to unrecognized fracture, or 
one in which perfect restoration of normal mechanical conditions has 
not been accomplished, is characterized by pain, tenderness, limited 
function, muscular atrophy, and at times bone thickening and deformity 
so great as to suggest malignant infiltration or tuberculosis. 

The diagnosis of the cause of the condition is usually dependent upon 
x-v2ij examination, but must often be made by exclusion, by careful 
consideration of the history, and by observation of the clinical course. 
The tibiotarsal and midtarsal joints are particularly affected by this 
form of chronic arthritis. 

Tuberculous Arthritis. — Tuberculosis of the tibiotarsal joint, commonly 
secondary to involvement of the astragalus or the tibial epiphysis, is 
manifested at first by a serous effusion, the fluctuating swelling incident 
to which is detected to either side of the extensor tendon, later by a 
uniform, elastic, indolent swelling involving the entire joint. 

Pain, limp, limitation of motion, muscular atrophy, onset and pro- 
gression without other adequate cause, and reaction to tuberculin are 
characteristic features. 

Tuberculosis of the midtarsal joint is characterized by the seat of 
swelling which is placed in front of the malleoli. Flexion and ex- 
tension movements are those least limited and least painful. 

The serous effusion of the ankle-joint incident to acute inflammation 
of the lower epiphysis of the tibia (rare) can be distinguished from 
a true arthritis only by the history of the onset of inflammatory symp- 
toms, the seat of maximum pain and tenderness, and possibly the a:-rays. 

The calcaneum is more frequently tuberculous than any of the other 
tarsal bones. Nor is the extension of the process so likely to invade the 
joints. The affection is characterized by an indolent, slowly progressive 
thickening of the bone, the swelling being most pronounced below the 
malleoli and its bone limitations being most distinctly marked when the 
infection lies farthest back. The ankle motions are not painful and are 
but little restricted. The a^-rays supplemented by the tuberculin test 
are diagnostic. 

If the calcaneo-astragaloid joint is involved, the submalleolar swelling 
is less distinctly outlined, and inversion and eversion are painful and 
are markedly limited. 

Tuberculosis of the metatarsals (rare) affecting by preference that of 

the great toe in adults, usually involves several bones. It is characterized 

by an indolent, fusiform swelling, exhibiting a tendency toward softening 

and fistulization. The distinction from syphilis is difficult, and depends 

37 



578 



THE LOWER EXTREMITY 

Fig. 371 




Tuberculous arthritis of ankle-joint. Patient aged twenty-two years. Joint symptoms for six 
months. Swelling most marked on outer and inner aspects of ankle. Motion limited. Position 
one of moderate plantar flexion. Fluctuation present. No heat or redness. Crepitation of joint 
surfaces. Atrophy of leg muscles. 

Fig. 372 




Gumma of ankle. 



Superficial sloughing ulcer of rounded outline and undermined edges 
lesion on shoulder. 



Similar 



THE LEG 579 

in the early stages upon the history, resuhs of the tubercuhn test and 
mercurial treatment, and finally upon the microscope. 

Tabetic Arthropathy. — ^Tabetic arthropathy, usually of slow develop- 
ment, often preceding other symptoms of the disease, is characterized 
by swelling and deformity which may ultimately become grotesque 
without the usual amount of pain, tenderness, and fixation. The mid- 
tarsal or the tibiotarsal joint, commonly both, are involved. The 
appearance may be suggestive of sarcoma. The want of correlation 
between the subjective and objective symptoms is almost diagnostic. 

Tumors of the Foot. — Of the benign neoplasms, lipoma is perhaps 
the commonest and may be congenital. It exhibits the softened consist- 
ency and the slow growth of this neoplasm as observed elsewhere. 

Exostoses are not uncommon in the heel, where they may give rise to 
pain on walking before they form a sufficient enlargement to be detected 
by palpation. Diagnosis may be made by the rr-rays. 

A subungual bony outgrowth, springing from beneath the nail of 
the great toe, occasions in its early stage of growth pain on pressure. 
Later, it lifts the nail. The slow growth (months, years) without inflam- 
matory symptoms, the dense consistency when palpation is possible, and 
the a;-rays establish the diagnosis. 

Chondroma, frequently multiple, having for its seats of predilection 
the metatarsals and phalanges, is characterized by dense nodulation, 
slow growth, and negative x-ray findings. 

Epithelial cysts are observed on the sole as on the palm. 

Angioma is often associated with a fatty growth; it is usually indicated 
by involvement of the skin vessels. The changes in size incident to 
vascular tension are characteristic. 

Sarcoma, occasionally congenital, growing from either the skin, sub- 
cutaneous tissues, or the bones, can be distinguished from benign 
lesions only by its rapid course. 

Developing as a subungual growth, if of slow progression, it cannot be 
distinguished from subungual osteoma except by excision and micro- 
scopic examination. Osteosarcoma simulates in its early stages chronic 
inflammation of the bone. The x-tsljs give a fairly characteristic picture. 
In its further development the bone tumor forms a more distinctly out- 
lined mass than do the inflammatory lesions, nor does it show an early 
tendency toward softening or fistulization. The metatarsals, the pha- 
langes, and the calcaneum are the bones most commonly invaded. 

Sarcoma should be diagnosticated by excision and microscopic exami- 
nation, the operation being performed when the tumor is first located 
by the a;-rays, provided it is probably not specific. 



THE LEG. 

The crest of the tibia is subcutaneous and readily palpable through 
its whole extent. The head of the fibula and the lower third of its 
shaft can also be felt. 



mo 



THE LOWER EXTREMITY 



t The abrasions and contused wounds to which the skin overlying 
the tibial crest and the malleoli is subject, because of a dependent posi- 
tion, constant use of the part, and often an associated valvular incompe- 
tence of the veins, are slow to heal. These lesions, whether they become 
acutely and repeatedly inflamed or develop into chronic ulcers, are 



Fig. 373 



Long saphenoiis vein. 




Vastus externus m. 

Rectus femoris m. 
Vastus internus m. 



Tendon of quadriceps femoris; sub- 
femoral bursa beneath it. 



Patella covered by prepatellar bursa. 



Line of knee-joint. 

Tendo patellae. 
Inner tuberosity of tibia. 
Anterior tibial tubercle. 
Head of fibula. 



Gastrocnemius and soleus muscles. 

Crest of tibia. 

Tibialis anticus muscle. 

Extensor longus digitorum muscle. 

Peroneus longus and brevis muscles 
covering the fibula. 



Surface markings of the leg and knee. Anterior surface. (G. G. Davis.) 



accompanied by an obstructing or obliterating lymphangitis which 
renders reparative processes slow and incomplete. Hence the leg is 
the common seat of chronic ulcers. 

Varicose veins of the leg, fundamentally incident to incompetent 
valves, are usually attributable to prolonged standing, or interference 



THE LEG 



581 



with the return flow, as from intra-abdominal pressure, thrombosis, 
tumor formation, or mitral regurgitation. 

Varicose veins, if superficial, are obvious to inspection and palpation. 
If deep, they are characterized by pain of a rheumatic character made 
worse by standing, edema about the ankle not otherwise to be accounted 
for, and dilatation of the small veins over the dorsum of the foot. 

Superficial varices are usually dependent for their progression upon 
valvular incompetence in the long saphenous vein. A similar condition 
in the short saphenous vein is less common. Valvular incompetence 
is determined by holding the leg and thigh in a vertical posture for 
several minutes with the patient supine. The lower third of the thigh 



Fig. 374 




Lymphedema of the leg. Extensive inflammatory exudate in left pelvis. Swelling in part 
disappeared vmder prolonged rest in bed, but recurred on getting up. Diffuse, firm swelling, 
yielding slight pitting on pressure, extending to top of shoe and crippling in character. 



is then bandaged with sufficient pressure to compress the superficial 
but not the deep veins, and the patient is put upon his feet. If the 
saphenous vein fills abruptly above the bandage, the valves are certainly 
incompetent. 

Varicose veins are complicated by eczema, leg ulcer, rupture and 
hemorrhage, thrombosis, embolism, and the formation of phleboliths. 

Thrombosis is characterized by the appearance of a tender cord in 
the course of the vein, usually accompanied by edema and skin red- 
ness. If septic, the thrombus exhibits the features and constitutional 
symptoms of abscess. The nodular, subcutaneous, usually multiple 
phleboliths are the traces of former thrombosis. 



582 



THE LOWER EXTREMITY 



Chronic Ulcer of the Leg. — Chronic ulcer of the leg raay be incident 
to the action of the ordinary pyogenic organisms upon an ill-drained, 
poorly vascularized skin and subcutaneous area, may be syphilitic, 
blastomycotic, tuberculous, or malignant, or may be an ultimate skin 
expression of suppurating bone lesion. 

Simple chronic ulcer, often associated with obvious varicosities, is 
observed at times in overfat, middle-aged people; usually in the aged, 
ill-nourished, and uncleanly. It has for its beginning an abrasion, a 
wound, an inflamed thrombus, a ruptured varicose vein, or a patch of 



Fig. 375 




Gumma of subcutaneous tissue. Painless, causeless, indurated, adherent to skin, 
over the underlying bone. Duration, weeks. 



Freely movable 



eczema. The affection, usually above the malleoli and on the lower 
third of the leg, is characterized by indolence and slow extension (months, 
years) which is mainly superficial, but may destroy tissues down to 
the bones. 

It is usually painless and unattended with constitutional symptoms; 
there is commonly an associated pronounced skin pigmentation, often 
obstinate eczema, occasionally lymphedema, producing a brawny swell- 
ing of the foot and leg. 

Syphilitic ulcer, often multiple, begins as a painless, non-inflamma- 
tory infiltration of the skin or underlying soft parts, which slowly reddens 



THE LEG 



583 



and softens (weeks), leaving a deep, punched-out, rounded ulcer with 
bacon-like walls. It is common in the upper third of the leg, a position 
so unusual for simple ulcer that this in itself is suggestive. When it 
occurs over the regions favored by simple ulcer and is not seen until its 
characteristic features are obscured by inflammation incident to irrita- 
tion and neglect of treatment, the diagnosis must depend upon the 
history, the presence of other lesions or their scars, and the therapeutic 
test. 

Tuberculous ulcer is usually a skin manifestation of underlying bone 
infection. It is characterized by feeble anemic granulations, under- 
mined skin, and a tendency to fistulization. 



Fig. 376 




G.umma of leg. Superficial ulcerating lesion, circular in outline, in upper half of leg. Eight weeks' 
duration. Began as painless swelling. No varicose veins. No trauma. 



Blastomycotic ulcer (rare) appears as a rounded, spreading, painless, 
indolent area made up of exuberant granulations containing multiple 
small abscesses. The diagnosis is based upon microscopic examination. 

Malignant degeneration of a chronic ulcer (Marjolin's ulcer) may be 
suggested by its nodular surface and border. The diagnosis must be 
made by the microscope. 

Erysipelas and cellulitis of the leg conform to type, nor is the diagnosis 
difiicult. Direct extension of infection from the foot through the synovial 
sheaths of the tendons is less common than is the case with the hand. 

Extension by the lymphatics and veins may involve either the super- 
ficial or the subaponeurotic tissues. 



584 



THE LOWER EXTREMITY 



Following slight foot infections, contusion or strain of the leg, or in 
the absence of these predisposing factors, there may be extensive collec- 
tions of pus, either beneath the skin, or subfascial between the muscles 
characterized by local and general symptoms of such moderate severity 
that diagnosis is not formulated until fluctuation is developed. 

Such purulent collections may gravitate from the popliteal space, 
may be an extension of chronic osteomyelitis of the bones with perfora- 
tion, or may be secondary to deep thrombosis. 

Contusion. — Contusion of the leg is often attended by extensive blood 
extravasation, producing a skin discoloration not unlike gangrene — the 
similarity is the greater if the skin be raised in the post-traumatic bullae 
which often complicate fracture. 



Fig. 377 




Bleb and vesicles following (hours) severe contusion of the leg. (Frazier.) 



Fracture of the Bones of the Leg. — The tibia and fibula are commonly 
both broken; if from direct violence, at the point of application of this; 
if from indirect violence, the fibula at a higher level than the tibia, even 
close to its upper extremity. 

The common seat of the tibial fracture is in the lower third. It is in 
direction usually oblique from above and behind downward and for- 
ward. 

Spiral fractures from twisting force are common and are usually 
comminuted. Fissures frequently pass downward to the ankle-joint. 
The lower fragment is comijionly displaced upward and backward. 

Diagnosis is usually obvious because of the gross deformity, or is 
readily elicited because of subcutaneous position of the tibial crest. 
Crepitus may be wanting because of soft parts interposed between the 
fragments. 

Measurements for shortening when these seem needful should be 
taken between the adductor tubercle and the internal malleolus. 

When the associated fibular fracture is placed high, its seat may be 
determined by local tenderness to deep palpation, often crepitus and 
lessened resistance to pressure or by preternatural mobility. 

Fracture of the tibia alone may occur without displacement, in which 
case the diagnosis will be suggested by persistent local tenderness and 



THE LEG 



585 



moderate disability. It is possible, however, for a person with such 
fracture to be comparatively able-bodied. The a^-rays constitute the 
final means of determining not only the presence of fracture, but its 
exact seat and its nature. 

Fracture of the fibula alone, usually in the middle third and from 
direct violence, is characterized in the absence of displacement, by local 
pain and tenderness on deep pressure; usually by crepitus and obscure 
preternatural mobility. The power of locomotion is not materially 
interfered with. 



Fig. 3781 



Fig. 379 




S X 





Fig. 378. — Uncomplicated fracture in upper portion of shaft, in a male, aged forty-six years. 
Clinical diagnosis somewhat difficult in absence of crepitus and because of thick covering of muscles. 
Pain and local tenderness most suggestive signs. 

Fig. 379. — Uncomplicated fracture about middle of the shaft in a male, aged thirty-one years. 
Cause, direct violence. 



1 Figs. 378 and 379. Fractures of the shaft of the fibiila above the lower fifth. Outline drawings 
from radiographs by Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; 
patients referred from services of Drs. White and Frazier. 



586 



THE LOWER EXTREMITY 



The lower third of the fibula is very commonly broken as a further 
manifestation of an everting force which ruptures the internal lateral 
ligament of the ankle-joint or tears loose the bony attachment. The 
seat of fracture is usually about two inches above the malleolus and is 
characterized by eversion of the foot, loss of resistance on deep pressure, 
marked local tenderness, and usually crepitus. 

Fracture of the upper extremity of the fibula may be unattended by 
the ordinary signs of the lesion aside from deep and persistent tenderness. 
Because of the close relation of the peroneal nerve and the neck of the 
fibula, fracture of the bone in this position is sometimes associated with 



Fig. 3801 



Fig. 381 





Fig. 380. — Fracture of the middle and upper thirds of the shaft in a child, aged six years. 
Cause, direct violence — struck by fender of trolley car. Typical example of incomplete fracture. 
Not diagnosticated clinically, purely an a;-ray diagnosis. Anteroposterior view. 

Fig. 381. — Old and partially united transverse fracture of upper and middle thirds of shaft in a 
male, aged fifty-three years. Was never diagnosticated or treated for a fracture. Radiograph 
made because of a second recent injury (negative). Note excessive callus for such a break. Shows 
necessity of x-ray examination for such injuries, even in absence of pathognomonic signs of fracture. 
Anteroposterior view. 



1 Figs. 380 to 386. Fractures of the shaft of the tibia. Outline drawings of radiographs by 
Dr. H. K. Pancoast in collection of University Hospital a;-ray Laboratory; patients referred from 
dispensaries. 



Flo. 382 



THE LEG 

Fig 383 



587 



Fig. 384 



c^ 






Fig. 382. — Incomplete fracture middle of shaft in a boy, aged five years. (Compound.) Note 
bending of fibula without fracture. Anteroposterior view. 

Fig. 383. — Lateral view of same case, shows that fracture must be very nearly complete. 

Fig. 384. — Very oblique fracture in lower third of shaft in a boy, aged fifteen years, caused 
by a horse falling on his leg. Clinical diagnosis not difficult. Lateral view. 

either rupture or contusion of this nerve trunk. Such injury is char- 
acterized by pain referred to its course of distribution, or local anesthesia 
and extensor palsy. 

Fractures of the lower third of the leg often fail to unite. This con- 
dition is characterized by prolonged disability and recurring pain on 
use, usually there is an enormous growth of callus and preternatural 
mobility. It may be difficult to elicit this last symptom. The findings 
of the a;-rays are conclusive. Fracture from trifling cause always sug- 
gests an underlying bone lesion. In the case of the tibia, bone cysts 
and central sarcomata should be considered. 

Inflammation of the Tibia and Fibula. — Osteoperiostitis of the 
tibia in its acute form may be due to traumatism or may appear as a 
local expression of systemic infection, particularly of syphilis or typhoid. 

Acute traumatic osteoperiostitis, incident to contusions, is characterized 
by excessive pain, great tenderness, swelling which is obviously attached 



588 



T'HE LOWER EXTREMITY 

Fig. 385 Fig. 38() 





Fig. 385. — Anteroposterior view of same case as Fig. 384. Remarkable in showing no evidence 
whatever of the fracture. 

Fig. 386. — Oblique spiral fracture in lower fourth of shaft in a man, aged seventy-eight years. 
Clinical diagnosis not difficult. Reduction (outward displacement and shortening) very difficult. 
Anteroposterior view after attempted reduction. (Lateral shows no displacement.) 

to the bone, and often a permanent thickening. Diagnosis from fissured 
fracture must be made by the ir-rays. Secondary suppuration is denoted 
by aggravation of symptoms with increasing edema. 

Syphilitic osteoperiostitis, which exhibits a preference for the tibia, may 
occur in either the secondary or tertiary stage of the disease. In the 
form of painful, extremely tender, rapidly developed nodules, it is an 
early secondary symptom which yields readily and completely to specific 
treatment. 

Gummatous osteoperiostitis, exhibiting a predilection for the lower 
third of the tibia, develops slowly and apparently causelessly, or follow- 
ing inadequate trauma. It is at times painless, or may be extremely 
painful. The diagnosis is based upon associated symptoms of syphilis 
and the prompt yielding to mercurial treatment. 

Typhoid Osteoperiostitis. — ^Typhoid osteoperiostitis is superficial, sub- 
acute, usually painless, follows the type as seen elsewhere. Diagnosis is 
based upon the apparent causelessness of a superficial subacute osteitis 
other than a preceding attack of typhoid fever. 

Acute Osteomyelitis. — Acute osteomyelitis exhibits a special predilec- 
tion for the tibia, attacking by preference the ends of the bone, often 
involving the entire shaft. Epiphyseal and joint involvements are 
secondary processes. 



THE LEG 



589 



In the hyperacute form the onset is characterized by the constitu- 
tional symptoms of profound sepsis, while locally there is intense pain 
which may be referred to the nearest joint, extreme sensitiveness to 
deep pressure, and absolute crippling. Edematous swelling of the soft 
parts rapidly supervenes. 

The effusions in the knee and ankle-joints, occurring as complications 
of osteomyelitis of the tibia, is in the early stages serous. Later, it may 
become seropurulent, or even frankly suppurative, the original infection 
being then complicated by the symptoms of a purulent arthritis. 

There is an acute non-suppurative osteomyelitis which can be dis- 



FiG. 387 



Fig. 388 





Fig. 387. — Fracture of both bones at about junction of upper and middle thirds of shafts, and 
about same level, tibia being comminuted. Radiograph made several weeks after injury, and indi- 
cates delayed union in tibia and no attempt at imion in fibula. Lateral Adew. (Male, aged thirty- 
five years.) 

Fig. 388. — Fracture of both bones just below middle of shafts. Both oblique; fibula slightly 
comminuted and tibial fracture very irregular. This fracture somewhat unusual from standpoint 
of cause, a fall from a roof, patient, a boy, aged eleven years, landing on his feet. Note fairly good 
apposition and position of fragments indicated in this view (fore-and-aft) and compare with 
Fig. 389. 



1 Figs. 387 to 400. Fractures of the shafts of both bones of the leg. Outline drawings 
from radiographs by Dr. H. K. Pancoast in collection of University Hospital x-ray Labora- 
tory; patients referred by or from services of Drs. Frazier, White, and Martin, and private 
cases of Dr. Pancoast. 



590 



Fig. 389 



THE LOWER EXTREMITY 

Fig. 390 



Fig. 391 




Fig. 389. — Lateral view of same case as Fig. 388 Note shortening and forward displacement 
of lower fragments, neither of which is indicated in anteroposterior view. 

Fig. 390. — Fracture of both bones at about lower and middle thirds of shafts, transverse, and at 
same level. This is the type usually resulting from direct violence at seat of fracture. Patient, 
male, aged twenty-four years. Anteroposterior view shown here indicates only an angular deform- 
ity. (Compare with Fig. 391.) 

Fig. 391. — Lateral view of same case as Fig. 390. Note additional deformity shown and 
requiring correction. 

tinguished from the phlegmonous form only by its slower progress and 
the absence of pus formation, the exudate being serous. 

The subacute form of osteomyelitis may develop with slight constitu- 
tional symptoms, moderate pain, tenderness localized in the bone, and 
local swelling. The exact seat of inflammation is determined by the 
a:-rays. The distinction from tuberculosis, rare as a primary lesion of 
the shaft, is based upon the seat of the inflammation, the examination 
of the pus discharge, and prompt recovery after extrusion or removal 
of the sequestrum. 

The diagnosis of the chronic, sclerosing, non-suppurative form of osteo- 
myelitis is based upon the persistence of pain, tenderness, and disability, 
in the absence of pronounced constitutional symptoms and the findings 
of the cc-rays. The onset of this form may closely simulate that of acute 



THE LEG 591 

Fig. 392 Fig 393 





Fro. 392 — Compound comminuted fracture of both bones at about lower and middle thirds of 
shafts, with fibular break at a slightly higher level. Cause was a fall from a second-story window, the 
patient, a male, aged about twenty-six years, landing on the foot of this side. Compare this 
fracture with the one represented in Figs. 388 and 389, which was due to practically the same 
cause. Fore-and-aft view. 

Fig. 393. — Lateral view of same case as Fig. 392, showing excellent apposition of fragments. 



osteomyelitis. It is a rare affection, complicated at times by acute 
suppurative inflammation in other bones, or sequent to a previous 
osteomyelitis. 

Abscess of the Tibia.- — In the cancellous structure of the upper part 
of the tibia an abscess may remain partly encapsulated for years, giving 
no symptoms, save tenderness to deep percussion and pressure, and 
thickening of the bone, either palpable or demonstrable by the ic-rays. 

There is a previous history of acute osteomyelitis, non-progressive in 
type, subsiding under local treatment without operation, but recurring. 



592 



THE LOWER EXTREMITY 



Fig. 394 



Fig. 395 





Fig. 394. — Fracture of both bones at about junction of middle and lower fourths of shafts. 
Both oblique, and fracture of tibia comminuted and tending toward the so-called ' 'spiral" 
type. Both bones broken at practically the same level. Anteroposterior view is represented and 
shows complete lateral displacement with over-riding. (Female, aged thirty-six years.) 

Fig. 395. — Fracture of both bones at different and unusual levels — tibia at lower and middle 
thirds of shaft and fibula just above its malleolus. Both oblique and readily permit shortening. 
(Male, aged fifty-three years.) Anteroposterior view. 



at least so far as pain and tenderness are concerned, at irregular intervals, 
and usually as a result of slight trauma or overuse. 

Positive diagnosis is suggested by the x-rays, and is made by trephin- 
ing the bone. Nor can timely differentiation from central sarcoma 
always be made in any other way. 

As the result of osteomyelitis the bone may be extensively destroyed 
or its growth may be stimulated or inhibited, with the local resultant 
deformities. 

Tuberculosis. — ^Tuberculosis of the bones of the leg is usually limited 
to the epiphysis, manifesting itself mainly in the form of chronic 



Fig. 396 



THE LEG 

Fig. 397 



593 



Fig. 398 





Fig. 396. — Fracture of both bones, comminuted, and at somewhat different levels, tibia, lower 
and middle fourths, and fibula throughout entire lower fifth. (Adult female.) Anteroposterior 
view. 

Fig. 397. — Fracture of both bones, with extreme degree of difference in levels. Both broken 
obliquely, tibia in lower fourth of shaft and fibula in its upper fourth. A striking example of the 
type of fracture resulting from indirect violence. (Male, aged seventy years.) Anteroposterior 
view. 

Fig. 398. — Fracture of both bones at about junction of middle and lower thirds of shafts, trans- 
verse, and nearly same level. Unusual cause. (Compare with Fig. 390.) Fracturing force must 
have been essentially a twisting strain resulting from an attempt to board a rapidly moving car. 
Left foot was fixed on step, but not caught, and carried forward, while the body and extremity 
above swung around relatively. (Male, aged twenty-three years.) 

38 



594 



THE LOWER EXTREMITY 

Ftg. 399 Fig. 400 





Fig. 399. — Compound fracture of both bones at same level and just above ankle, broken trans- 
versely, and in addition a longitudinal fissure through lower tibial fragment extending downward 
to epiphyseal line, but not through the epiphysis. Injury resulted from direct violence — crushed 
under a car wheel. (Male, aged eighteen years.) 

Fig. 400. — Fracture of both bones at different levels, tibia at junction of lower and middle 
thirds of shaft obliquely, and fibula comminuted through entire malleolus. (Adult male.) 



arthritis. Early recognition of the focus of infection by the ir-rays may 
be the means of saving the joint. 

Exceptionally it attacks the shaft of the bone, usually as an extension 
from the epiphysis. The onset is insidious and slowly progressive, and 
there is a tendency toward fistulization. 

When the tuberculous process invades the entire shaft of the bone 
(rare) it exhibits a more acute onset than is usual with this form of 
infection, but is thereafter characterized by its slow, steady progression 
and the ultimate development of characteristic fistulse and sequestra. 

Diagnosis is usually based upon the presence of tuberculous lesions 
elsewhere, the result of the tuberculin test, the characteristic, thin, 
cheesy, purulent discharge, microscopic examination, and particularly 
animal inoculations. 



THE KNEE 



595 



Fig. 401 



Tumors. — Malignant tumors originating in the soft parts of the 
leg are not common. A cancerous degeneration of a chronic ulcer has 
been mentioned. Sarcoma in its beginning cannot be differentiated 
either from lipoma or fibroma, excepting by excision. This should 
be the means of diagnosis. 

The tibia is the favorite seat of bone sarcoma, both in its periosteal 
and central form. It is usually placed near the extremity and in its 
early stages does not differ in • 
symptomatology from a chronic 
or subacute osteomyelitis. The 
periosteal sarcoma in its further 
development forms a palpable 
tumor, fusiform and not exhib- 
iting either the nodulation or con- 
sistency of exostoses or chondro- 
mata. The a^-rays are strongly 
suggestive; diagnosis should be 
made by operation. 

Persistent deep-seated pain is 
the usual symptom of central 
sarcoma. During this stage a 
probable diagnosis can be made 
by the a;-rays. It should be cor- 
roborated if gumma can be ex- 
cluded by immediate operation. 
The later development of these 
tumors is usually characterized by 
rapid growth and the attainment 
of large dimensions before ulcer- 
ation or fistulization takes place. 

Bone cysts usually give rise to 
few symptoms other than a slight 
enlargement of the bone. They 
are slow in growth and their pres- 
ence is often first suggested by 
spontaneous fracture on slight 
traumatism. The :r-rays are 
usually diagnostic. 




Epithelioma. Indolent (years), indurated, 
infiltrating, fungating lesion growing from a 
chronic ulcer. 



THE KNEE. 

The thick, coarse skin, with comparatively little subcutaneous 
fat, covering the front of the knee-joint, is more redundant and freely 
movable than that of finer structure, and provided with an abundant 
panniculus lying at the sides and back of the joint. 

The patella, with the leg straight and the quadriceps relaxed, is 
freely movable from side to side, and readily palpated even in fat sub- 
jects. 

The condyles of the femur, of which the internal is the more promi- 



598 THE LOWER EXTREMITY 

nent, can be palpated, the adductor tubercle placed at the upper border 
of the inner condyle forming its most prominent bony projection. The 
inner and outer tuberosity of the tibia, the latter being more prominent, 
the end of the fibula, the upper extremity of which is about a finger's 
width below the line of the joint, the tubercle of the tibia at about the 
same level, with the patellar ligament inserted into it, are all easily 
identified. 

The tendons of the semitendinosus and semimembranosus forming 
the inner upper margins of the popliteal space, and of the biceps forming 
its outer margin, are conspicuous landmarks. The lymphatic glands 
of this space cannot be felt in normal individuals. They occupy a 
midline position and drain the superficial area corresponding with the 
distribution of the short saphenous vein, including a part of the sole 
and the knee-joint. 

To either side of the patella and above it, excepting in fat people, 
there is a depression, the obliteration of which is characteristic of joint 
effusion. The depressions at the sides of the ligamentum patellae, best 
marked in moderate flexion, are obliterated in fat people by an increase 
in the fat pad, which, with lateral extensions, normally lies between the 
ligament and the joint. 

The line of the joint is roughly indicated by the lower border of the 
patella. The synovial membrane reaches a higher point over the front 
of the inner condyle than it does over the outer. It usually exhibits an 
anterior pouch extending for a distance of two fingers' breadth above 
the upper border of the patella. This prolongation may be entirely 
separate from the joint, or may communicate with it by a narrow 
opening. 

Of the many bursse placed about the knee-joint, those most frequently 
involved in surgical affections are : the prepatellar bursae, of which there 
may be three, separate or intercommunicating, lying between the various 
layers of the fibrous investment of the anterior surface of the patella; 
the infrapatellar bursa, placed between the ligamentum patellae and the 
tubercle of the tibia, with the pad of fat naturally lying in this position 
interposing between it and the joint; the bursa between the gastroc- 
nemius and the semimembranosus tendon, lying to the inner side of the 
popliteal space and above the line of the joint. 

The tibia normally joins the femur in a position of slight varus. 

The motions of the knee-joint are flexion, limited by contact of the calf 
muscles with the flexors of the thigh, extension to the straight position, 
and, when the leg is moderately flexed on the thigh, rotation; this 
necessarily implies a slight degree of lateral rocking. 

Surgical affections of the knee-joint are characterized by deformity, 
swelling, pain, tenderness, muscular contraction and atrophy, and 
limitation or exaggeration of motion. 

Deformity, usually obvious to inspection or palpation, may require 
an ^-ray examination for its detection. The swelling, if intra-articular, 
is characterized by a fllling out of the normal depressions at the sides of 
and above the patella, and, if it be due to effusion, by a floating up of 



THE KNEE 



597 



Fig. 402 



this bone. Extra-articular swelling, if localized, is obvious to inspec- 
tion and palpation. 

The pain of knee-joint affections, unless this be referred (usually 
from the hip) or be neuralgic in type, is aggravated by motion, by deep 
palpation and jarring, and is subject to spasmodic exacerbation incident 
to muscular contraction. 

In localized lesions the seat of pain and tenderness is usually indica- 
tive of the seat of lesion. 

Muscular atrophy develops most rapidly and is most pronounced in 
the quadriceps, though all the muscles concerned in the joint move- 
ment become involved. 

Limitation of motion, if incident to 
an inflammation, is due in the early 
course to pain and muscular spasm, 
later to fibroid changes or bony anky- 
losis. Exaggerated lateral or antero- 
posterior movements are characteristic 
of ligamentous rupture from trauma or 
of overstretching from failure of muscle 
support or intra-articular effusion. 

Deformities of the Knee. — Gross 
congenital deformities such as absence 
of the patella are obvious on inspection. 

Genu Recurvatum. — Genu recurva- 
tum, a term applied to over-exten- 
sion, may be congenital or acquired. 

The congenital form is often accom- 
panied by other deformities, particu- 
larly club foot. The popliteal space is 
prominent, and there may be inability 
to flex. 

The acquired form is commonly due 
to club foot which places an undue 
strain upon the knee. Inherent liga- 
mentous relaxation, hip-joint fixation, 
or direct injury may cause this de- 
formity. 

Pain, discomfort, and hyperextension 
during weight-bearing are the charac- 
teristic features. The diagnosis is made 
by inspection. 

Genu Valgum. — Genu valgum, or knock-knee, which usually develops 
in infancy or childhood, exceptionally about the period of puberty, 
incident to overuse, is commonly attributed to rickets, though a failure 
of muscular coordination and habitual faulty attitude may be causative 
factors. With the knees pressed together and the patient standing, both 
tibiae incline downward and outward, and the feet are more or less 
widely separated. The condition is usually bilateral and is associated 
with genu recurvatum and flat foot. 



1 


f 




f 

1 

i 
1 


\ 




\ 







KJiock-knee (genu valgum). Knees 
in apposition. Feet widely separated. 
Patient in habit of carrying heavy bas- 
kets, which he permitted to press 
against outer side of knees. (Carnett.) 



598 THE LOWER EXTREMITY 

Genu Varum. — Genu varum, or bow leg, is usually dependent upon a 
deformity not of the knee-joint, but of the upper portion of the tibia. 
It is customarily associated with inward rotation of the tibia producing 
a pigeon-toe gait. Diagnosis is obvious. 

Ankylosis. — ^Ankylosis of the knee-joint, either bony or fibrous, is the 
after result of previous inflammation. The diagnosis is obvious and the 
amount of joint destruction can best be determined by the x-rays. 

Contractures of the knee-joint, exceptionally congenital, frequently 
secondary to inflammation in or about the joint, or sequent to infantile 
palsy, are characterized by partial fixation of the knee in a faulty posi- 
tion, usually more or less pronounced flexion, often combined with out- 
ward rotation and subluxation backward. 

Trauma of the Knee. — The immediate effects of trauma applied 
to the knee are wound, contusion, sprain, fracture, or luxation. The 
usual injuries are contusion and sprain. 

Wound. — Wound of the knee is obvious. If it be large the presence or 
absence of joint penetration is readily determined. Punctured wound 
or foreign body may cause a synovial effusion even though the joint is 
not involved. In case of doubt as to the nature of this effusion, aspira- 
tion and examination of the exudate are indicated. 

Contusion. — Contusion of the knee, if it involves the soft parts alone, is 
characterized by moderate and ephemeral pain, rapid, often extensive 
skin discoloration, and, if the prepatellar bursa be involved, a blood 
effusion into the sac causing a distinctly circumscribed fluctuating or 
semisolid tumor. 

When the joint is contused, usually from force applied to the inner side 
of the patella when the knee is flexed, there are severe persistent pain, 
marked disability and rapid intra-articular effusion with prompt discolora- 
tion at the seat of impact. 

Because of the immediate swelling and the extreme tenderness, asso- 
ciated cartilaginous or bone lesions usually escape detection until their 
presence is suggested by slow and unsatisfactory convalescence. The 
exclusion of bone lesion should be accomplished by the ic-rays. 

Sprain. — Sprain of the knee, usually involving the internal lateral 
ligament, and incident to any force tending to exaggerate the natural 
slight genu valgum, is characterized by severe pain, local tenderness, 
discoloration, usually effusion into the joint, and, if the ligament be rup- 
tured, increased lateral mobility, with at times a slight displacement of the 
tibia upon the femur, the former bone carrying with it the intact semi- 
lunar cartilages. This condition, really a recurring subluxation of the 
tibia, usually due to considerable violence, constitutes one form of dis- 
location of the semilunar cartilage, and is characterized by a weak joint 
subject to sudden painful locking, incident to slight force in the direction 
of rotation while the leg is semiflexed and the muscles are relaxed. 
These painful lockings are followed by synovial effusion. 

Subluxation of the semilunar cartilage, usually the inner and in a for- 
ward direction, is due to forcible inward rotation of the femur upon the 
flexed tibia. It is characterized by severe pain, usually fixation of the 



THE KNEE 599 

joint in flexion, rapid effusion, tenderness over the semilunar cartilage, 
and in the case of forward displacement palpable deformity. Since this 
displacement always implies a ligamentous rupture, there is left a w^eak 
joint with tendency to recurrence of acute painful displacement upon 
slight traumatism. 

Rupture of the semilunar cartilage, the usual injury when this structure 
can be felt projecting externally or when it is driven internally (rare), and 
its absence can be noted, exhibits the symptomatology described under 
subluxation. 

The after effects of these injuries are recurring attacks of neuralgic 
pain associated with a joint subject to synovial effusion from overuse or 
slight strain. In some instances there develops a chronic synovitis with 
effusion, capsular thickening, creaking, and recurring attacks of sudden 
fixation. 

Rupture of the ligamentum patelloe exhibits the disability of fractured 
patella with a break in the continuity of the ligament detected by direct 
examination. Unless the rupture be close to the tibial attachment of the 
ligament, there will be effusion of blood into the joint. 

Rupture of the quadriceps tendon, characterized by severe pain, partial 
or complete loss of extending power, local tenderness, and a break in the 
continuity of the tendon, is readily felt by palpation, even though it be 
obscured by the free subcutaneous hemorrhage common in this injury. 

Rupture of the crucial ligaments, incident to either hyperextension or 
rotation, often associated with a tearing loose of a bony fragment from 
the femur, is characterized by severe pain and rapid blood effusion into 
the joint. Preternatural mobility of the tibia on the femur in an antero- 
posterior direction, usually associated with lateral wobbling, is character- 
istic, as is also the finding of a loose bony fragment in the joint by the 
x-rsijs. 

Contusion or tear of the alar ligaments, the ligamenta mucosa, or the 
synovial fringes, incident to trauma not sufficiently severe to cause rup- 
ture of the stronger ligaments, is characterized by the tenderness, pain, 
disability, and joint effusion typical of contusion or sprain. As a sequel 
to such injury, convalescence is slow and incomplete. Either free or 
attached bodies are prone to develop; these may be fatty, fibrous, car- 
tilaginous, or even calcareous. 

Osteoarthritis of the Knee. — Osteoarthritis of the knee, either in its 
hypertrophic or atrophic form, may be limited to the joint, but is usually 
associated with similar lesions of other joints. The atrophic form, 
usually affecting women of middle age or before it, exhibits the gradual 
onset, pronounced muscular atrophy, spindle-shaped swelling, and joint 
creaking characteristic of the affection. The hypertrophic form, occur- 
ring frequently at a more advanced age, may attack the knee alone and 
remain limited to it. Slow progression (years) of symptoms, slight or 
absent exudation, obvious bony and cartilaginous deformity, and absence 
of constitutional symptoms are suggestive symptoms. Absolute diag- 
nosis can be made by the rr-rays. 

In its chronic form hemophilia is characterized by recurrent attacks 



600 



THE LOWER EXTREMITY 



of intra-articular hemorrhage followed by extensive destruction of joint 
surfaces, producing ultimately the changes characteristic of advanced 
osteoarthritis. In the absence of the hemophilic history or aspiration 
of blood from the joint, the distinction from tuberculosis or osteoarthritis 
of other origin may be difficult. 

Fractures about the Knee. — The break may involve the patella, the 
epiphyses of the femur or tibia, or their condyles or tuberosities. 

Fracture of the patella, an affection of active adult males, is usually 
incident to a sudden violent pull of the quadriceps tendon and is 
transverse. When caused by direct violence, the fracture lines are 
often multiple, running in any direction. 

The characteristic symptoms are a sudden and painful loss of the power 
of extending the leg, following a blow, or a muscular effort in which 



Fig. 4031 



Fig. 404 




Fig. 403. — Transverse fracture of patella, in adult male, ununited six months after injury. 
Example of usual type and about average amount of separation of fragments. Note forward 
and downward tilting of lower fragment in this case. 

Fig. 404. — Fracture of patella similar in type to preceding one, in a male, aged twenty-two years, 
six weeks after open operation and wiring. Radiograph indicates some bony union between deeper 
portions of fragments. 



1 Figs. 403 to 406. Fractures of the patella. Outline drawings from radiographs by Dr. H. K. 
Pancoast in collection of University Hospital x-ray Laboratory; patients referred by or from services 
of Drs. Wood, Frazier, and Martin. 



THE KNEE 



601 



Fig. 405 



Fig. 406 





Fig. 405. — Refracture in. same case as Fig. 404, resulting from a fall about six weeks later. 
Radiograph suggests partial untwisting of wire and loop unbroken and still tending to prevent 
wide displacement. (Open wound rendered fracture compound, and septic arthritis followed.) 

Fig. 406. — Comminuted fracture of patella, in adult male, result of direct violence — fall from a 
ladder, striking on knee. Radiograph three hours after injury. Clinical diagnosis of fracture and 
variety not difficult, but x-rays important to determine amount of comminution and separation 
before operation, and also advisability of latter. 



something is felt to have broken. If the fracture be complete and the 
fibrous expansion to either side of the patella be torn, there is marked 
separation of the fragments, and a groove which is widened by flexion 
can be felt between them. The amount of separation depends upon 
the extent to which the lateral aponeurosis of the quadriceps muscle is 
involved. There is an immediate blood effusion into the joint, often 
also into the prepatellar bursa. 

Fractures due to direct violence are evidenced by skin ecchymoses 
at the point of impact and usually by comminution. 

The diagnosis in case of wide separation is readily made. When the 
separation is slight, owing to preservation of the ligamentous attach- 
ments, it may depend upon eliciting preternatural mobility, the patella 
being grasped from above and below and the parts being pressed 
alternately from side to side. 

Blood effusion into the prepatellar bursa may give the examining 
finger an area of lessened resistance and a crepitation simulating 



602 



THE LOWER EXTREMITY 



fracture. The patella is firm throughout, and flexion of the leg does 
not increase the apparent space. 

Fracture of the femur near the knee-joint, or involving it, may be condy- 
lar or epiphyseal. These fractures are incident to great force, usually 
indirect, are often compound, and, except the epiphyseal, involve the 
joint. They are frequently complicated by lesions of the vessels and 
nerves of the popliteal space. 

Fracture of the condyles is due to direct or indirect force, the shaft 
of the femur in the latter instance acting as a down-driven wedge. It 
always involves the joint, hence is attended by rapid swelling from blood 
effusion. 

One condyle alone may be involved. Usually the break is inter- 
condyloid and communicates with a transverse fracture above. The 
fragments are displaced outward and upward, and, unless the swelling 
be excessive and the tenderness prohibitive, crepitus and preternatural 
mobility are readily elicited. 

The x-rays are necessary for a complete diagnosis, since displacement 
of the articular surfaces may be pronounced, and yet not readily 
demonstrable by any other means. 

Fig. 4071 




Separation of lower epiphysis of femur, with complete anterior and upward displacement, in a 
boy, aged eleven years. Caused by foot being caught in spokes of a wagon wheel while ' 'stealing 
a ride." Lateral view, before reduction. 



1 Fig. 407. Outline drawing from radiograph by Dr. H. K. Pancoast in collection of University 
Hospital x-ray Laboratory; patient referred from service of Dr. Martin. 



THE KNEE 



603 



Fracture of one condyle may be unattended by either undue mobility 
or deformity, joint effusion, persistent local tenderness, and disability 
being the only obvious symptoms. 

Fracture of the adductor tubercle (rare) is characterized by local per- 
sistent tenderness and bony outgrowth. The diagnosis is made by the 
ic-rays. 

Separation of the loiver femoral epiphysis, usually observed before the 
tenth year, impossible after the twentieth, is characterized by preternatural 
mobility and a deformity which may strongly suggest luxation. The 



Fig. 4081 



Fig. 409 




Fig. 408. — Example of a so-called "sprain fracture," in a male, aged thirty-seven years ' A 
small, scale-like fragment has been separated from the outer surface of the head of the tibia, probably 
representing tearing away of attachment of lateral ligament. Injury caused by wheel of a wagon 
passing over the region of the patient's knee. 

Fig. 409. — Fracture of head of tibia, comparable to a fracture of both tuberosities, or a so-called 
"T-fracture," but without separation of fragments or widening of joint. Radiograph suggests more 
or less impaction. Exact clinical diagnosis of such fractures difficult, and x-rays of great assistance. 
View represented nearly but not directly anteroposterior. An important feature is involvement of 
the joint. Male, aged sixty years. 



1 Figs. 408 to 412. Fractures of the bones of the leg at the knee. Outline drawings from radio- 
graphs by Dr. H. K. Pancoast in collection of University Hospital x-ray Laboratory; patients 
referred by or from services of Drs. White and Wood. 



604 



THE LOWER EXTREMITY 



Fig. 410 



Fig. 411 





Fig. 410. — Fracture of head of tibia, similar in type to preceding one, but presenting more com- 
minution, appreciable separation, and slight widening of joint. Also an additional fracture through 
neck of fibula. Patient (female, aged fifty-four years) was struck by a trolley car. 

Fig. 411. — Fracture of head of tibia and neck of fibula, in female, aged fifty-eight years. Peculiar 
type, but presenting some features of preceding case. Not essentially a fracture of both tuberosities, 
but primarily a separate break through upper portion of shaft, which reaches outer surface of 
bone, whence the line is practically continuous with that of fracture through middle of outer tuber- 
osity. 



lower end of the upper fragment usually projects in the popliteal space, 
the lower fragment being carried forward and often so rotated that its 
broken surface is in apposition with the shaft of the diaphysis. The 
adductor tubercle remains attached to the shaft and the tibia retains 
its normal relations to the condyles. The age of incidence, the com- 
paratively smooth, broken surface when this can be felt, possibly the 
moist crepitus, and the a:-rays establish the diagnosis. 

Fracture of the upper end of the tibia, incident to direct violence or jar 
in the long axis of the bone may be transverse or longitudinal, without 
involving the joint. Usually the line of fracture runs directly into the 
joint and results in separation of one or both tuberosities. 

In addition to the hemarthrosis, disability, preternatural mobility, 
and local tenderness exaggerated lateral mobility is highly character- 
istic, the rocking being most marked in the direction of the fractured 
tuberosity. Diagnosis should, however, be made by the x-rays. This 



THE KNEE 



605 



Fig. 412 




Fracture of head of tibia with distinct impaction and some separation of lateral fragment 
representing tuberosities, causing slight widening of joint. Also a fracture of upper portion of 
shaft of fibula. Caused by a jump from a second-story window. Female, aged forty-two years. 



frequently shows fissures in the absence of the cardinal symptoms of 
fracture. 

Separation of the upper tibial epiphysis (rare), possible up to the 
twentieth year, is observed mainly in males. It is characterized by dis- 
placement of the leg in any direction, except backward, the tuberosities 
of the bone maintaining their normal relation to the joint. The a:-rays 
are diagnostic though the seat of fracture, transverse direction, and 
moist crepitus may be suggestive. 

Diagnosis is based upon the obvious deformity and its seat. 

Separation of the tubercle of the tibia incident to muscular action, and 
observed usually in athletic boys, is characterized by tenderness, pain 
and swelling in the region of the tubercle, and by the finding of the 
movable bone fragments if the separation be complete. 

In the absence of complete separation, the persistence of tenderness, 
pain, disability, and bone swelling are suggestive symptoms which may 
be corroborated by the a^-rays. As a consequence of partial fracture 
there may be a bony outgrowth in this region. 



606 THE LOWER EXTREMITY 

Dislocation of the Knee-joint. — The tibia may be displaced from the 
femur in any direction, usually as the result of very great violence, 
readily recognized by the obvious and palpable deformity. 

The patella may be dislocated either outward or inward, or may be 
rotated on its vertical axis through a quarter or half circle. 

The diagnosis is readily made by inspection and palpation. The 
outward luxation is the commoner form and may occur from muscular 
action, doubtless predisposed to by congenital formation, the outer lip 
of the intercondyloid notch being defective. 

Weakness of the vastus internus muscle, genu valgum, and chronic 
arthritis predispose to habitual luxation. 

Luxation of the fibula from the tibia (rare), usually forward and out- 
ward, is characterized by a depression at the usual site of the fibular 
head and the presence of this bony prominence in an abnormal position. 

Subluxation of the semilunar cartilage, an injury to which vigorous 
young men are subject, is usually due to violent outward rotation of the 
leg on the thigh when the limb is in a position of slight flexion. Twists 
such as occur in running jumping, skating, or even dancing, are common 
causes. The inner cartilage is the one customarily involved (see p. 598). 

Periarticular Inflammation. — The skin of the knee, particularly on 
its anterior surface, is subject to abrasion, furuncle, abscess, and to the 
secondary and tertiary lesions of syphilis. These lesions conform to 
type. Those of acute inflammatory origin not infrequently involve the 
patellar bursa in a suppurative inflammation followed, in the absence 
of appropriate treatment, by persistent sinus formation. 

Secondary lesions of syphilis are always attended by other corroborative 
signs of the disease. Dermal and subdermal gummata exhibit a special 
predilection for the soft parts overlying the patella. Indeed, they not 
infrequently start in this bone. They are characterized by painless 
infiltration which slowly (weeks) breaks down into a circular ulcer with 
a bacon-like base. 

Acute inflammation of the popliteal space, unless it be caused by a 
wound, is usually due to adenitis, secondary to an infection of the foot 
and leg which may have been so slight as to escape notice, or to a similar 
condition of the glands incident to subcutaneous hemorrhage or to over- 
use. Tenderness, pain radiating down the leg, slight sense of fulness in 
the popliteal space, often the detection of a tender, swollen gland of small 
size are the symptoms noted. Suppuration is characterized by its usual 
local and constitutional signs. 

In some cases these symptoms are but slightly marked, the pus 
burrowing from the popliteal space along the course of the bloodvessels 
and forming collections in the intermuscular septa of both the anterior 
and the posterior tibial group. The symptoms are expressed in the leg 
as fluctuating swellings attended with moderate disability, some pain, 
and a low grade of sepsis. 

Acute thrombophlebitis, either suppurative or simple, is frequently 
developed in dilated subcutaneous veins about the knee-joint, particu- 
larly those of the long saphenous group overlying the inner condyle. 



THE KNEE 



607 



Induration along the vein is characteristic. In suppurative cases it is 
shortly obscured by the inflammatory swelling. Because of the move- 
ments of the joint, thrombi formed about the knee are particularly 
likely to be carried into the general circulation. 

Thrombosis of the popliteal vein, expressed by tenderness and indura- 
tion along the course of this vessel, engorgement of the external popli- 
teal vein, edema of the foot and leg, usually by constitutional symptoms 
of infection, which in the case of septic thrombosis become of high grade 
and are accompanied by the local features of acute phlegmon. 

Bursitis. — Of the many bursae about the knee-joint the prepatellar is 
the one most frequently involved in both acute and chronic inflamma- 
tion. The infrapatellar, the pretibial, and the bursa placed between the 
^gastrocnemius muscle and the semimembranosus tendon are affected 

Fig. 413 




Chronic prepatellar bursitis. (Housemaid's knee.) Twenty years' duration. Swelling began 
one week after punctured wound. Knee-joint normal. Swelling situated in front of patella. 
Fibroid thickening of walls of bursa. Fluctuation present. Skin normal. (Blockley Out-ward.) 



next in order of frequency, usually in the form of a chronic inflam- 
mation expressed by serous effusion, the dominant symptom being the 
presence of a fluctuating tumor. 

Acute pi'epatellar bursitis, secondary to trauma, or an overlying 
suppurating skin lesion, is marked by fluctuating swelling beneath the 
skin, between it and the anterior surface of the patella. 

Blood effusion immediately after trauma often gives a crepitation 
suggestive of fracture, but distinctly softer. Serous effusion is char- 
acterized by the absence of inflammatory symptoms. Purulent involve- 
ment exhibits characteristic local and general symptoms of suppuration, 
with often an edematous swelling so widespread that involvement of 
the joint is suggested. 



608 THE LOWER EXTREMITY 

A serous exudate into the joint may occur as a complication, but 
arthritis is readily excluded by free movements and absence of true 
joint tenderness. 

Chronic prepatellar bursitis incident to slight repeated trauma, as from 
kneeling, or consequent on failure to properly treat an acute inflammation, 
is characterized mainly by a persistent fluctuating tumor in the position 
of the bursse. Greatly thickened walls may simulate a solid tumor. 

Tuberculous prepatellar bursitis, occurring independently of patellar 
involvement, exhibiting more inflammatory thickening and greater 
sensitiveness than that incident to the non-tuberculous form of involve- 
ment, can be diagnosticated in the absence of other tuberculous lesions 
only by excision and microscopic examination, or the application of 
the tuberculin test. 

lufrapatellar bursitis is marked by a fluctuating swelling appearing 
to either side of the ligamentum patellse and by pain during the act of 
extension. The cushions of fat lying in this region sometimes become 
hypertrophied and closely simulate a bursitis. Through fluctuation 
cannot, however, be elicited. 

Pretibial bursitis forms a swelling in front of the tibial spine between it 
and the skin. 

Gastrocnemius-semimembranosus bursitis causes a fluctuating swelling 
in the popliteal space. Normally the U-shaped bursa may be multi- 
locular, and in muscular subjects not infrequently communicates with 
the joint or with a second bursa, which in turn has a joint communi- 
cation. An effusion into the bursa secondary to overuse, trauma, or 
without obvious cause, forms a tumor at first to the inner side of the 
popliteal space, later filling the greater portion of this space. It is tense 
and prominent on extension of the knee, is deeply attached to the flexor 
tendons, fluctuates, becoming soft on flexion, and sometimes exhibits 
the quality of reducibility into the joint. Occasionally crepitation due 
to rice-like bodies may be perceived. 

Mechanical limitation of flexion, weakness of the knee-joint, and 
pain are the dominant symptoms. Later there may follow edema from 
pressure on the bloodvessels. The affection may be bilateral. 

The distinction from cold abscess and from lipoma may be difficult. 
The former has usually definite joint symptoms of slowly progressive 
development. Nor is the fluctuating tumor formed by it likely to be so 
definitely outlined. If of bone origin, which is usual, the x-rays should 
demonstrate osseous lesion. This may be so slight as to show no clear 
picture, and the abscess may have formed independently of the joint. 
The differential diagnosis has often been made only at operation. 

Biceps Bursitis. — Acute or chronic inflammation of the bursa lying 
between the biceps tendon and the external lateral ligament, because 
of the proximity of the peroneal nerve, may be attended by severe pain 
radiating down the leg. The swelling lies over the head of the tibia, and 
in its development extends backward toward the popliteal space. 

Popliteal bursitis forms a cystic swelling primarily located in the lower 
outer part of the popliteal space. 



THE KNEE 



609 



Aneurysm of the Popliteal Artery.— Aneurysm of the popliteal 
artery, a favorite seat, common in hard-working, hard-drinking syphil- 
itics, is usually characterized by some limitation of the joint movement 
and pain in the popliteal space radiating downward into the leg. Later 
there develops a tumor usually with an expansile pulsation, bruit, and 
thrill. The effect upon the size of the tumor of pressure upon the artery 
above and below is the most characteristic symptom. Acute inflam- 
matory phenomena may develop, the symptoms then closely resembling 
abscess or bursitis. 

Fig. 414 




Subacute serofibrinous effusion into the knee-joint. Duration, six weeks; in patient with subacute 
total gonorrheal urethritis. Fluctuating swelling confined to limits of joint cavity. Obliteration 
of normal depressions in front of knee. Slight enlargement of superficial veins. Skin normal in 
color. Pain and disability not pronounced. - 



Inflammation of the Knee-joint. — Acute Traumatic Arthritis. — Acute 
traumatic arthritis, incident to contusion, sprain, or fracture, is charac- 
terized by a rapid effusion into the joint (minutes or hours, if hemor- 
rhage), evidenced by floating of the patella and fulness about its sides, 
pain, tenderness, and disability. Under rest the symptoms usually 
promptly subside. Their continuance or aggravation under use suggest 
an uncured fracture which may be a fissure without displacement, injury 
to the semilunar cartilages, thickening of the synovial fringes, or liga- 
mentous or muscular relaxation of such nature and extent as to put the 
joint to mechanical disadvantage when used. Persistent aggravation 
of symptoms after slight traumatism adequately treated should in young 
people suggest the possibility of beginning tuberculosis. 
39 



610 THE LOWER EXTREMITY 

Following fracture of the shaft of the femur, particularly its lower 
third, there is very commonly observed a synovial effusion into the knee- 
joint of sufficient extent to float the patella. In young people it subsides 
promptly. 

An acute rapid effusion into the knee-joint from what would usually 
be inadequate trauma is typical of hemophilia. A suggestive history 
usually can be elicited. The diagnosis has often not been suspected 
until aspiration demonstrated a joint cavity filled with blood. 

The joint effusion may be serous, serofibrinous, or suppurative, the 
first attended by practically no constitutional symptoms; the second by 
those of moderate severity, usually incident to the severe pain char- 
acteristic of it; the third by the local and general evidences of profound 
intoxication. 

Gonorrhea and rheumatism are the usual systemic causes of acute 
inflammation of the knee-joint. 

Gonococcal Arthritis. — Gonococcal arthritis in its serous form is 
attended with rapid and usually painful swelling, not infrequently in- 
volving both knees. The patella is usually floated up so wide of the 
femur that it cannot be tapped against it. Fluctuation is obvious. 
The diagnosis is based upon the finding elsewhere of a focus of gonor- 
rheal infection and an examination of the joint contents. 

This serous exudate may exhibit a tendency to recur incident to slight 
relighting of long standing, often unrecognized urethral infection. The 
recurrences are marked mainly by effusion, the patients exhibiting an 
absence of pain and a functional ability which are considered char- 
acteristic of the tabetic joint. 

The plastic form of gonorrheal arthritis is attended by slight intra- 
articular exudate, dense periarticular infiltration, harassing pain, rapid 
muscle atrophy, constitutional symptoms of moderate severity, and 
partial or complete ankylosis. 

The suppurative form (rare) exhibits the local and general symptoms 
of pus-formation. Early diagnosis is best made by aspiration or incision 
into the joint, and examination of its contents. 

Acute Rheumatic Arthritis. — Acute rheumatic arthritis is character- 
ized by the rapid onset of a serous exudate. It is usually extremely 
painful and is attended with other symptoms of rheumatic infection, i. e., 
migratory character of the joint involvement, moderate fever, rapid 
pulse, and copious acid sweats. The diagnosis, however, should not be 
formulated until other causes for acute arthritis have been excluded. 

Exanthematous, influenzal, typhoidal, pneumonic, and pyemic inflam- 
mations are recognized as such in accordance with their association 
with the major disease. 

Chronic Traumatic Arthritis. — Chronic traumatic arthritis, a sequel 
of acute traumat'sm, unless it be definitely associated with the symp- 
toms of loose cartilage, free body, or relaxed ligaments, can be recog- 
nized as traumatic only after careful exclusion of infecting causes, a 
distinct history of adequate trauma, and an estimation as to the curative 
effects of rest. 



THE KNEE 



611 



Any of the forms of acute infectious arthritis may become chronic, this 
being particularly true of a gonococcal infection. 

The two infections which begin insidiously and are chronic from the 
first are tuberculosis and syphilis. 

Tuberculosis of the Knee. — Tuberculosis of the knee, beginning, as a 
rule, in the femoral or tibial epiphysis, commonest in children and adol- 
escents, is occasionally seen in young adults, exceptionally at a more 
advanced age. 

Fig. 415 




Typical soft, non-adherent, rounded, grouped scars of a tertiary skin syphilide. Duration, years. 

It is characterized by apparent causelessness, insidious onset, and 
slow progression. Intermitting limp is usually the first symptom to 
attract attention, and is associated with tenderness and limitation of 
motion due to muscular spasm, neither extreme extension nor complete 
flexion being possible. Tenderness varies in position in accordance 
with the seat of primary infection. Swelling is easily demonstrable 
because of the accessibility of the joint. There is muscular atrophy 
most marked in the extensor region. 

Sometimes there is severe pain which may be paroxysmal or constant. 
Exceptionally there is a subacute onset which simulates acute infection. 



612 



THE LOWER EXTREMITY 



In its further development the affection is characterized by an elastic, 
at times hard, swelling which obscures the outlines of the joint; muscular 
atrophy and contracture which may produce a partial backward luxa- 
tion of the tibia upon the femur, often associated with outward rotation 
and genu valgum; at times slight lengthening of the bone involved 

from epiphyseal irritation; usually 
Fig. 416 shortening incident to bone de- 

struction followed by abscess 
formation. 

Early diagnosis is based upon 
the persistence and the steady 
progression of an apparently 
causeless chronic inflammation in 
the knee-joint of a child. The 
exact seat of invasion may be 
shown by the ic-rays before the 
joint is directly involved. 

Associated tuberculous lesions 
elsewhere and the positive results 
of the tuberculin test are diag- 
nostic aids. 

The distinction between a tu- 
berculous knee and one that is 
contused or sprained is based 
upon the history of adequate trau- 
matism and the prompt and com- 
plete disappearance of symptoms 
of contusion or sprain under 
appropriate treatment. Early 
active and persistent use of a 
contused knee may result in a 
condition of chronic synovitis 
which closely simulates local tu- 
berculosis. 

Sarcoma involving the ex- 
tremity of the femur or tibia is 
at first characterized chiefly by 
severe localized pain, which may 
be referred to the knee. When the tumor appears it is usually charac- 
terized by a growth far more rapid than that observed in local tubercu- 
losis. In the case of sarcoma the x-roiys may be diagnostic. 

Persistent pain, unrelieved by treatment appropriate to tuberculous 
gonitis, with localization of bone lesion by the iu-rays should suggest a 
differential diagnosis by early operation. 

Syphilitic Arthritis of the Knee. — Syphilitic arthritis of the knee, in 
its tertiary chronic form, so closely simulates that due to tuberculosis 
that a diagnosis must depend upon the history, the reaction, the treat- 
ment, and the tuberculin test. The syphilitic affection is rare in 




Tabetic arthropathy (Charcot's disease) of 
the knee-joint. Insane patient with locomotor 
ataxia. Relaxation of ligaments. Effusion 
and nmnerous loose bodies in joint. Absorption 
of articular surfaces. Functionally useless, pain- 
less joint. (Carnett.) 



THE KNEE 613 

children. It usually begins in the femoral epiphysis and is exceedingly 
painful. 

Neuropathic Arthritis of the Knee. — Neuropathic arthritis of the knee, 
at times preceding other manifestations of ataxia, is characterized by 
the sudden and painless onset of joint effusion without local or general 
inflammatory phenomena, aside from edema which may be widespread. 
There is but little disability. In its complete development the aft'ection 
is characterized by gross deformity, relaxed ligaments, often subluxation. 

The large tumor-like formation with dilated veins suggests in appear- 
ance sarcoma. The absence of subjective symptoms, the comparatively 
slight interference with function, and the associated ataxic manifestations 
suggest the diagnosis. 

Painful Conditions of the Knee without Local Lesion. — The so-called 
growing pains, common in the knee-joint, often marked after overuse 
and doubtless incident to transient moderate congestion, are unattended 
by limp, limitation of motion, joint effusion, or atrophy. 

Pain may be referred to the knee as the result of pressure or inflam- 
mation of the anterior crural, obturator, or great sciatic nerves. Such 
pain is not limited to the knee. 

Inflammatory affections of the hip-joint are particularly characterized 
by reference of pain to the knee. To a less marked degree similar 
reference occurs in affections of the kidney, ureter, bladder, prostate, and 
uterus. Freedom and painlessness of movement suggest the reflex 
origin of the pain. 

Neuralgia of the knee-joint is characterized by pain and tenderness 
following inadequate trauma, varying in seat, and out of proportion to 
the local flndings. There may be muscular fixation, increase of surface 
temperature, skin hypersensibility, and slight swelling. Because of 
pressure upon the vein, edema of the leg is often marked. Diagnosis 
is based upon the disagreement of symptoms and signs, the absence of 
muscular atrophy, the negative flndings of the rr-rays and exclusion by 
repeated careful examination for the lesions of tuberculosis and syphilis. 

Such symptoms occurring in an hysterical subject are usually local 
manifestations of this condition. 

Tumors of the Region of the Knee-joint. — Benign tumors origi- 
nating in the soft parts are, with the exception of popliteal lipoma, 
generally recognized as such only because at the time they come under 
observation they have been present so long and exhibited such slow 
growth that malignancy can be ruled out. AVhen seen in their early 
development diagnosis should be made by removal and microscopic 
examination. 

Lipoma placed in the popliteal space beneath the deep fascia forms a 
rounded, semifluctuating tumor, the distinction of which from bursitis 
may be possible only by exploratory operation. 

Sarcoma begins precisely as do the benign tumors. A diagnosis should 
be made by prompt removal before rapidity of growth suggests the nature 
of the tumor. 

Exostoses from the epiphyseal line of the femur or tibia are common. 



614 



THE LOWER EXTREMITY 



They develop before puberty, are slow in growth, extending in a spur-like 
manner away from the joint. They may be hereditary and symmetrical. 
They are often of traumatic origin. The ic-rays are diagnostic. 

Bone sarcoma, having for its seats of predilection the upper portion 
of the tibial and the lower portion of the femoral diaphysis, usually 
sparing the joint cavity, may be central or peripheral in origin, semi- 
benign, or highly malignant. The early diagnosis is based upon per- 
sistent, often intense, sharply localized pain, usually attributed to 
rheumatism and treated as such, and particularly upon the findings of 

Fig. 417 



sIVHHHMB^^H^MI 



Knee-joint containing two loose bodies, only one of which was demonstrable by a;-rays. Chronic 
serous synovitis with repeated mild acute exacerbations. Loose bodies palpably slipping around in 
joint. (Carnett.) 



the a:-rays. When the tumor becomes manifest to palpation and inspec- 
tion, its rapid growth is in itself characteristic. The vascular type may 
give both pulsation and feeble bruit. 

Dilatation of the superficial veins and crepitation from the cracking 
of the thin shell of overlying bone are late symptoms. 

The early diagnosis from tuberculosis is suggested by the intensity 
and persistence of the pain, the futility of rest and extension in relieving 
this, the negative evidence of the tuberculin test, and particularly by the 
x-Ydij findings. 

Even a clear a:^-ray picture may not satisfactorily distinguish a cyst 



THE THIGH 615 

or central sarcoma from inflammatory affections, hence, given a lesion 
which is non-syphilitic, the diagnosis both as to its nature and its relative 
malignancy should be made promptly by operation, which at times must 
be supplemented by microscopic examination. 

The rapid course and development of tumor and the absence of 
joint involvement are later characteristic. 

Loose Bodies in the Knee-joint. — Unless such bodies can be shown 
by the a;-rays, or are so placed that they can be palpated, the diagnosis 
must be based upon an otherwise causeless chronic synovitis, associated 
with a recurring partial or complete locking of the joint in the perform- 
ance of certain motions. Exceptionally joint crepitation, sudden weak- 
ness causing falls, and synovial effusion constitute sufficient ground for 
exploration of the joint, particularly in fat people with well-developed 
subpatellar fat pads and presumably redundant and fatty alar ligaments. 



THE THIGH. 

Contusions. — Contusions of the thigh are attended by an abundant, 
subcutaneous blood eff\ision which, because of the loose dermal attach- 
ment, may form large, fluctuating or semisolid, crepitating tumors. 
As the result of repeated traumatism there may form a persistent fluctu- 
ating subcutaneous tumor, the contents of which closely resemble clear 
or slightly blood-stained synovia. 

Repeated trauma or overuse causes a myositis, characterized by 
tenderness, induration of the muscles involved, and pain so severe on 
use as to be crippling. It is a condition frequently noticed in the 
extensor muscle of football players. 

Rupture of the Thigh Muscles. — Rupture of the thigh muscles, involving 
particularly the adductors and extensors, commonly observed in those 
who attempt athletic feats without adequate training, is characterized 
by sudden, severe, crippling pain with local tenderness and palpable 
break in continuity if the seat of rupture be superficial. Osseous growth 
may take place at the seat of rupture; this is particularly true of such 
injuries of the adductors. 

Hernia of the muscle is occasionally observed in the thigh (see p. 108). 

Of the various dermal lesions furuncle is particularly common in 
the region of the hip. 

Varicosity of either the long saphenous vein or of the lymphatic 
vessels passing to the glands lying in the saphenous opening may form 
superficial, soft, lobulated masses in this region which, in the case of 
vein dilatation, may give impulse on coughing. 

Psoas Abscess. — Psoas abscess, or one of pelvic origin, may burrow 
downward beneath the thick, investing fascia of the thigh, forming a 
large fluctuating tumor. 

As in the leg, extensive intermuscular or subcutaneous pus accumulation 
may occur without bone lesion or other obvious cause; usually in the 
cachectic, and characterized by moderate sepsis of the adynamic type 



616 THE LOWER EXTREMITY 

and local inflammatory symptoms so slightly marked that fluctuation 
first leads to the suspicion of pus. 

Aneurysm. — Aneurysm, which may spring from any part of the 
femoral artery, exhibits some or all of its characteristic features (see 
p. 99). 

Sciatica. — Sciatica, common in middle-aged men, is characterized by 
pain, usually paroxysmal and increased by all movements which stretch 
the nerve, and tenderness on deep pressure over its trunk. The points 
of maximum sensitiveness are just below the border of the gluteus muscle 
midway between the tuber ischii and the great trochanter and the mid- 
portion of the popliteal space. There is usually associated muscular 
weakness with exaggerated reflexes. Bilateral sciatica is usually indica- 
tive of spinal lesion. 

Pain along the sciatic nerve is a common and early symptom of 
inflammation of the sacro-iliac joint. It is also characteristic of myositis, 
follows trauma, and is a common manifestation of pressure from pelvic 
tumor or inflammation. There is usually in chronic cases a scoliosis 
with its lumbar convexity toward the affected side. 

Fracture of the shaft of the femur, from direct or indirect violence or 
muscular action, has for its common seat the middle third, and is usually 
extremely oblique from above downward and forward. The break 
may be just below the lesser trochanter or above the condyles. There is 
marked shortening, the lower fragment lies posteriorly, and is usually 
rotated outward, the foot lying flat on its side. 

In the subtrochanteric fracture the upper fragment is pulled forward 
by the iliopsoas muscle and rotated outward. In the supracondyloid 
fracture the lower fragment is commonly rotated backward by the gastroc- 
nemius muscle. 

Complicating injuries of the bloodvessels, exceptionally the nerves, 
are not infrequent in these fractures, particularly those above the knee, 
and should be looked for in the examination 

At times the fracture of the shaft is spiral and comminuted, a long, 
wedge-shaped portion of bone being entirely separated from the two 
main fragments. 

In children the fracture may be transverse and subperiosteal, in which 
case there may be little or no deformity. Green-stick fracture is also not 
uncommon in them. 

The diagnosis of fracture of the femur, if it be complete, is usually made 
by inspection. The outward rotation of the leg and the obvious shorten- 
ing, often angulation, combined with absolute disability indicate the 
nature of the lesion. 

The measurements for shortening are taken on each side from the 
anterior superior spine of the ilium to the internal malleolus, the legs 
and thighs occupying the same relative position to the midline of the 
body in regard to flexion, rotation, and abduction. A second measure- 
ment from the top of the trochanter to the external malleolus should 
be taken and should show the same amount of shortening when this is 
dependent upon overlapping of the bones of the femur. 



THE THIGH 



617 



Preternatural mobility is easily elicited, crepitus may be wanting 
because of interposition of muscular tissue. 

Acute osteomyelitis of the femoral shaft, having for its seat of predilection 
the spongy tissue at either end of the diaphysis, occurring most frequently 
in boys and often incident to slight trauma or chilling, exhibits character- 
istic symptoms of hyperacute infection, severe pain, total loss of function, 
tenderness on deep pressure, and shortly edematous swelling of the 
entire circumference of the thigh at the seat of involvement. The early 
diagnosis is made by operation, the x-rays not being helpful at this time. 

Necrosis, sinus formation, sequestration, are late developments often 
attended by pronounced permanent deformity. 

Chronic osteomyelitis, usually incident to tuberculosis or syphilis, 
often following an acute attack, sometimes chronic from the first even 

Fig. 418 




Pedunculated fibrolipoma of thigh. Fifteen years' duration. Surface irregular. Skin normal 
and slightly movable. Unevenly firm in consistency. (Carnett.) 



though incident to staphylococcic infection, is evidenced by deep and 
persistent pain and tenderness, with moderate disability, slight con- 
stitutional symptoms, and bone thickening, first demonstrable by the 
a:-rays, later distinctly palpable, and at times involving the entire bone 
shaft. Sequestration and sinus formation are usual but not invariable 
sequelae. 

The early distinction from malignant growth is not possible except 
by the x-rays, and, when the inflammatory process is localized, must 
often be made by operation. 

Tumors of the Thigh. — Benign tumors of the bone appear in the 
form of exostoses and chondromata, growing from the epiphyseal line 



618 



THE LOWER EXTREMITY 



of young people. Such exostoses are subject to malignant degeneration, 
hence when they grow rapidly the diagnosis of their benignancy should 
be based upon removal and examination. 

Lipoma. — Lipoma is occasionally observed in the superficial fascia 
and corresponds to type, forming a lobulated, rather sharply circum- 
scribed mass, with dimpling of the skin on pinching it up. It may 
form a diffuse tumor either in the superficial or deep fascia and is not 
infrequently associated with an angioma, in which case the diagnosis 
may be suggested by the soft consistency, slow growth, usually con- 
genital origin, and marked change in size incident to elevation and 
depression. 

In the case of deep vascular growths there is often an angiomatous 
condition of the overlying skin. Exceptionally lipoma beneath the deep 

Fig. 419 




Fibrolipoma of the thigh. Twelve years' duration. Overlying skin unaltered and non-adherent. 
Tumor firm in consistency, situated beneath deep fascia, and movable in surrounding tissues. 
(Carnett.) 



fascia may be circumscribed, forming a distinctly hard tumor. The 
distinction from sarcoma can be formulated only on the much slower 
growth of the fatty tumor and by operation. 

Carcinoma. — Carcinoma, excepting that involving the skin, occurs in the 
metastatic form and may be the underlying lesion of a spontaneous 
fracture. 

Sarcoma. — Sarcoma originating in the periosteum or. soft parts has 
for its seat of predilection the adductor portion of the thigh. It is 
characterized by rapidity of growth. Any recent, apparently causeless 
tumor in this region should suggest the probability of sarcoma. 

The thigh is particularly the region of both bone sarcoma and 
that originating in the connective tissue of the soft parts. The bone 



THE HIP 



619 



sarcoma is characterized by fixed, harassing pain, later by spontaneous 
fracture or swelhng. Early diagnosis is possible only by the ic-rays or 
operation. 



Fig. 420 




Epithelioma in cicatrix following burn. (Hartzell.) 

Bone cyst, being of slow growth, gives few symptoms. Tumor may 
be first noticed; often fracture from inadequate force is the earliest 
indication of a lesion. The diagnosis is made by the a;-rays. 



THE HIP. 



The coarse skin of the buttock, particularly subject to boils, covers, 
in addition to the gluteal muscles, much fat and loose connective tissue. 
Lipomata and extensive blood effusions, from moderate trauma, are 
common in this region. 

About the hip-joint are placed a number of bursse, the more impor- 
tant of which, surgically, are the trochanteric, the iliopectineal, and the 
ischial. The trochanteric bursa lies between the deep surface of the 



620 THE LOWER EXTREMITY 

gluteus maximus and the lateral trochanteric surface; there are other 
smaller bursal sacs lower down between the muscle and the femoral 
shaft. 

The large iliopectineal, called also the iliopsoas bursa, lies in front 
of the capsule of the hip- joint between this structure and the iliopsoas 
tendon; a second smaller bursa lies below, nearer the femoral attach- 
ment of the muscle. 

The ischial bursa lies over the prominence of the ischium, between 
this structure and the gluteus maximus. 

The lymphatics of the buttock empty into the inguinal and the deep 
pelvic glands. 

In the groin, which is limited above by Poupart's ligament and exter- 
nally by a line drawn from the anterior superior spine to the top of the 
trochanter, lie two sets of lymphatic glands. The superficial set, in the 
superficial fascia, containing many single elements, parallels both 
Poupart's ligament and the long saphenous vein. The deep set, con- 
sisting of a few glands, lies to the inner side of the femoral vein. Into 
these glands drains the lymph of the lower extremity, the buttock, the 
anus, the perineum, the external genitals, and the lower part of the 
abdominal parietes. 

The strong ball-and-socket hip-joint moves in all directions with a 
range subject to marked individual variation. Usually the thigh can 
be flexed until its extensor surface is in contact with the belly wall. With 
the patient in ventral decubitus and the pelvis held firmly, but slight 
extension is possible. Abduction, adduction, and the rotation are free 
within their limits. 

In the examination of the hip-joint, the bony landmarks of impor- 
tance are the anterior superior spine of the ilium, reached by fol- 
lowing the crest of the ilium forward, the tuberosity of the ischium, 
the bony projection on which the weight is borne while sitting, and the 
trochanter major, indicated by a depression in fat subjects, made more 
prominent by adduction and internal rotation, with its upper border 
obscured by the middle gluteal muscle. The posterior superior iliac 
spine representing the posterior extremity of the iliac crest, and often 
indicated by a dimple, marks about the centre of the sacro-iliac 
joint. 

The gluteal fold, representing the crease of demarcation between the 
thigh and buttock, lies above the lower border of the gluteus maximus. 
With the patient standing upright, heels together, it should be symmetri- 
cal on the two sides. It is obscured or obliterated by flexion and by 
deep or superficial swellings. 

A line drawn from the anterior superior iliac spine to the ischial 
tuberosity, the thigh being slightly flexed, crosses the palpable top of 
the trochanter (Nekton's line). From this standard of conformation 
many normal individuals depart. The line is serviceable mainly in 
comparing the trochanteric position on the two sides of the body and 
then only when the person examined is neither overfat nor heavily 
muscled; and when he can be partially turned on his side and the. 



THE HIP 621 

trochanter is not obscured by blood effusion or inflammatory swell- 

Bryant's triangle is made by dropping a line vertically from the anterior 
superior iliac spine to the flat surface on which the patient is lying 
supine, running a second line from the anterior superior spine to the 
top of the trochanter, and a third from this point perpendicular to 
the vertical line first drawn. This last line, called Bryant's line, is 
shortened as compared to that of the sound side if the trochanter be 
carried upward as from dislocation, fracture, or deformity of the 
femoral neck. 

The normal angle made by the junction of the axis of the shaft of the 
femur with that of its neck is in the adult about 130 degrees. Behind 
the femoral artery, just below the point where it crosses the pelvic brim, 
lies the head of the femur. 

The symptoms of affection of the hip-joint are pain, tenderness, 
swelling, muscular contraction and atrophy, limitation or exaggeration 
of motion, deformity, and the local and constitutional manifestations of 
infection. 

The pain of hip-joint affection is aggravated by motion or jarring of 
the joint. In the early stages of inflammation it may be referred to 
the knee. 

Pain may be referred to the hip as a result of lesion elsewhere; 
appendicitis, seminal vesiculitis, affections of the prostate, ovaries, 
tubes, or uterus commonly exhibit this reference. Referred pain is 
uninfluenced by movements or jarring of the joint, though it excep- 
tionally occasions a limp. The symptoms of the causative lesion are 
usually pronounced. 

Swelling incident to moderate joint effusion is not appreciable to 
touch. The swelling usually felt is periarticular, representing, in case 
of joint involvement, bony thickening, inflltration of soft parts, bursal 
involvement, or abscess formation. The fluctuating swellings of chronic 
bursitis are characterized by their position. 

Muscular contraction, usually first expressed in the iliopsoas, limit- 
ing extension, is an early symptom of joint inflammation. The atrophy 
is earliest demonstrable in the gluteal region unless there be inflamma- 
tory swelling here, though all the thigh muscles participate. 

Malformations of the Hip- joint. — Congenital Dislocation, exhibiting 
a predilection for girl babies, usually unilateral and due to develop- 
mental defect, exceptionally traumatic, is often not detected in fat 
children until they begin to walk; this is especially the case when the 
deformity is bilateral. 

^^^len the affection is unilateral, shortening of the leg, elevation and 
undue prominence of the trochanter, and flattening of the buttock are 
suggestive symptoms, the diagnostic one being the palpation of the 
abnormally mobile head in its wrong position, facilitated by adducting 
and rotating the thigh and pulling and pushing upon it. The ability 
to cause the trochanter to m3ve up and down by alternately pushing 
und pulling the leg is highly characteristic. 



622 THE LOWER EXTREMITY 

Bilateral luxation is characterized by the symptoms of the unilateral 
affection, except that, since both legs are shortened, there is no standard 
for comparing measurements. 

When the walking age is reached the limp in the unilateral involve- 
ment, with compensatory lordosis and scoliosis, the waddling gait 
in bilateral involvement, with compensatory lordosis and prominent 
buttocks and belly, associated with the symptoms already given, is 
characteristic. The it^-rays give the easiest and surest means of making 
a diagnosis. 

Coxa Vara. — Coxa vara is a deformity of late childhood and puberty, 
commonest in boys, characterized usually by downward and backward 
bending of the neck of the femur and consequent lessening of the angle 
formed by its long axis with that of the shaft. It is an affection of 
gradual development, sometimes secondary to fracture of the neck, 
epiphyseal separation, rickets, or tuberculosis. It is usually independent 
of such causes. 

Coxa vara is characterized by limp, weakness, and pain in the hip 
region moderate in degree and aggravated by use, outward rotation of 
the thigh, and prominence and upward displacement of the trochanter. 

Examination shows limitation of abduction and also to some extent 
of inward rotation and flexion. Actual shortening of the limb is readily 
demonstrated; this is rendered apparently greater by the tilting of the 
pelvis toward the sound side to compensate for the limited abduction. 

The distinction from tuberculous coxitis is based upon the obvious 
deformity which precedes crippling disability, and by the freedom of 
extension which is characteristic of coxa vara. In tuberculous coxitis 
limitation of extension is one of the earliest and most characteristic 
signs. 

In congenital luxation of the hip-joint the head of the bone may be 
felt in its abnormal position. Shortening can be lessened by traction 
and can be increased by pushing the femur upward. The exact seat 
of deformity can be determined only by the ^-rays. 

Coxa Valga. — Coxa valga, a condition in which the angle made by 
the neck of the femur with its shaft is increased, occurs in flabby 
adolescents, causing pain in the hip, lameness, and stiffness of the 
joint, often intermittent at first, and usually an outward rotation of the 
femur, with abduction, limitation of flexion, and stiffness of the joint 
due to spasmodic contraction of the muscle. There is necessarily an 
increase in the length of the limb. Diagnosis is based upon ar-ray find- 
ings. There is associated anterior bowing of the neck of the femur, 
the trochanter minor pointing directly inward instead of backward and 
inward. 

Contracture and ankylosis of the hip- joint are usually caused by a 
preceding joint inflammation. 

A flexion contracture incident to psoas involvement secondary to 
spinal caries is distinguished by the absence of tenderness in the hip- 
joint, its free motions within the limits imposed by the involved muscle, 
and the symptoms of Pott's disease. 



THE HIP 623 

Rheumatic contraction affecting children and marked by rapid 
onset and severe pain on motion, the joint being fixed in moderate 
flexion with either adduction or abduction, can be distinguished from 
beginning tuberculous coxitis only by the prompt curative effect of 
appropriate treatment. In its mild form it is characterized by recurring 
transitory limp. Pain is the dominant symptom. 

Habit contracture incident to long maintenance of flexed position 
is less common in the hip than in the knee-joint. 

The contracture, partial fixation, and deformity incident to senile 
arthritis deformans, have the associated joint symptoms and the ic-ray 
picture of the affection. 

The gross deformity of tabetic arthropathy is painless and is accom- 
panied by other characteristic symptoms of thfe disease. 

Paralytic contractures usually associated with dislocation backward 
if the abductors and external rotators are involved, forward if the 
paralysis has crippled the adductors, is characterized by muscular 
atrophy and elastic fixation in either flexion, adduction and internal 
rotation, or abduction and outward rotation, and the finding of the head 
of the bone in its abnormal position. 

Ankylosis incident to a previous inflammation is compensated for 
by increased mobility of the spine and the sacro-iliac articulation. It 
is a common sequel of gonococcal and rheumatic inflammation. 

Tuberculous inflammation is more prone to result in extensive destruc- 
tion of the head and neck of the bone and upward displacement of the 
trochanter. Coxitis of typhoid origin is frequently complicated by 
backward luxation. 

The determination of bony fixation, because of the mobility of the 
pelvis, is difficult, and is best determined by the x-rays. 

Trauma of the Hip. — Contusion of the Soft Parts. — Contusion of the 
soft parts exhibits extensive blood effusion which is slowly absorbed. 
Either the iliopsoas or the ischiatic bursa may, as a result of blood 
effusion, form a prominent, fluctuating or semisolid, crepitating, circum- 
scribed tumor lying in the bursal region and persisting after the sub- 
cutaneous blood effusion has been absorbed. The diagnosis is based 
upon the history of trauma and the seat of tumor. Such traumatized 
bursse may subsequently become the seat of hygromata. 

Contusion of the Hip-joint. — Contusion of the hip-joint is evidenced 
by local pain, and the signs of bruising, often associated with the com- 
plete disability, extreme tenderness, and outward rotation which are char- 
acteristic of fracture. Since the latter, if intracapsular, may be attended 
with none of the well-marked signs of this condition, the differential 
diagnosis may be impossible without the help of the x-rays. 

An injury to the hip sufficiently severe to cause complete disability 
is usually a fracture, the patient rarely having the power, when the leg 
is broken and non-impacted, of flexing the thigh even to a slight degree 
on the pelvis. 

Contusions of the joint attended with much less marked symptoms 
may in young people produce epiphyseal separation or incomplete 



624 THE LOWER EXTREMITY 

fracture of the neck suggested by slow and incomplete convalescence 
and ultimate deformity. The a;-rays afford the only means of making 
an early diagnosis. 

Fractures in and about the Hip-joint. — The fracture may involve the 
trochanters, the neck of the femur or its head, or the acetabulum. 
Usually they are of the femoral neck. 

Fractures of the Neck of the Femur. — The injury may be an 
epiphyseal separation of the head, a fracture of the junction of the 
head and neck, which may be incomplete or impacted, a fracture of 
any portion of the neck, or a fracture of the junction of the neck and 
trochanter, often impacted and both intracapsular and extracapsular. 

In children traumatic separation of the head of the femur at the 
epiphyseal line or fracture of the neck of the bone may be partial 
or complete. The complete fracture is usually impacted with down- 
ward bending of the neck. It is due to a heavy fall upon the hip, 
resulting in local pain and swelling, and disability characteristic in its 
extent of that of bruise rather than of fracture. Recovery is, however, 
neither rapid nor complete. There is continual lameness and dis- 
comfort. 

The diagnosis is based upon a careful examination which shows eleva- 
tion of the trochanter of the affected side (one-half to one inch), and 
usually limited abduction, flexion, and inward rotation. The positive 
diagnosis of these injuries should be made by the a;-rays. 

In the adult the seats of fracture are at the junction of the head and 
neck and the junction of the neck and shaft. In the former position 
the break is always intracapsular and is exceptionally impacted. It 
results from application of force in the long axis of the femur, as from 
unexpectedly slipping down a stair, or falling upon the knee, or from 
trifling violence. 

Fracture at the junction of the neck and shaft is usually comminuted 
and intracapsular in front and extracapsular behind, or entirely extra- 
capsular, and is frequently impacted, this impaction being more marked 
posteriorly. It results from a fall upon the hip, which, except in the 
aged or those subject to fracture, must be heavy. 

Fractures of the neck of the femur are characterized by disability 
which may be only partial in impacted fractures; by shortening, as 
shown by measurement from the anterior superior spinous process 
of the ilium to the internal malleolus, the interspinous line being at 
right angles to the long axis of the body and the legs of the two sides 
being held in similar position both in their relation to this line and in 
regard to their degree of flexion and rotation; by elevation of the tro- 
chanter to the extent of the shortening as determined by Bryant's line; 
by lack of parallelism between two lines, one of which connects the two 
anterior superior iliac spines, the other the tips of the trochanters; by 
outward rotation, the back of the heel of the injured side lying in con- 
tact with the tendo Achillis on the sound side when the legs are brought 
together; by lessened resistance in the space between the top of the tro- 
chanter and the crest of the ilium; by crepitus, in free fractures, elicited by 



THE HIP 



625 



pressure upon the trochanter, supplemented by traction and movements 
of the joint; by rotation of the trochanter about the arc of a circle with 
a less diameter than that of the sound side. There is, moreover, swell- 
ing, most rapid and pronounced when the fracture is extracapsular, 
pain greatly aggravated by motion, and tenderness on palpation most 
marked at the seat of injury. 

When the shortening and external rotation are slight, the disability 
not complete, the swelling pronounced and rapid, the pain severe, the 
trochanter obviously widened to the examining hand, blood effusion and 
skin discoloration prompt and widespread, and the injury is due to 
direct violence to the trochanter, it is probable the fracture is extra- 
capsular and impacted. Under such circumstances, unless there be 
great deformity, no effort should be made to elicit crepitus or undue 
mobility. 

When the injury is trifling and not directly applied to the trochanter, 
even though there be but slight shortening of Bryant's line, if absolute 



Fig. 4211 




Fracture through small part of neck of femur, in female, aged fifty-four years. Ununited (with 
shortening) eight weeks after injury. Injury neither diagnosticated nor treated as a fracture. 



1 Fig. 421. Outline drawing from radiograph by Dr. H. K. Pancoast in collection of Univer- 
sity Hospital x-ray Laboratory. (Referred by Dr. Willard.) 

40 



626 THE LOWER EXTREMITY 

disability is associated with pronounced outward rotation, it is probable 
the fracture is intracapsular and non-impacted. 

Contusion of the thigh does not cause shortening, but, since in frac- 
ture the latter may be so slight as to be difficult of demonstration, the 
differential diagnosis must be made by the a;-rays. 

Fracture of the great trochanter due to direct violence, rare except 
as a complication of fracture of the neck, then usually comminuted, 
can be detected in the absence of mobility or displacement only by the 
x-Y2ijs, or by severe and persistent bone pain and tenderness and the 
elimination of other lesions. 

The distinction between fracture, the common injury, and luxation, 
which is comparatively rare, is based upon the characteristic and elas- 
tically fixed position of the thigh and leg in backward luxation and the 
obvious displacement of the head of the bone and the trochanter in 
those rare dislocations characterized by outward rotation and abduction. 

Fracture of the acetabulum, usually a chipping off of a portion of its 
brim and constituting a complication of luxation, may be suggested by 
deep crepitus on manipulation, easy reduction of a partial luxation 
and a tendency toward recurrence of deformity on removal of extending 
force. An assured diagnosis of this condition is rarely possible without 
the use of the ;r-rays. 

Extensive fracture of the acetabulum may be suggested by shortening 
of the leg of the affected side, absence of the normal prominence of 
the trochanter, and by comparatively easy reduction of the deformity 
by extension with its recurrence on removal of the extending force. 
Rectal examination has sometimes revealed crepitus and blood effusion. 
Diagnosis should be made by the o^-rays. 

Luxation of the Hip-joint. — Traumatic dislocation of the hip-joint, 
commonest in vigorous adult males, is characterized by an elastic fixa- 
tion of the thigh, which varies in accordance with whether the head of 
the bone lies without (behind) or within (in front of) a line passing 
from the anterior superior spinous process of the ilium to the ischial 
tuberosity. 

Outward or posterior luxation (iliac or ischiatic) is characterized by 
flexion, adduction and inward rotation incident to the pull of an intact 
Y-ligament, and shortening. If the Y-ligament be ruptured, the position 
will depart from type. The head of the displaced bone can often be 
felt beneath the gluteus muscles, and its absence from the normal position 
will be shown by loss of deep resistance on pressure upon the femoral 
artery just below the pubic bone. The trochanter is displaced upward. 
Involvement of the sciatic nerve will be indicated by severe pain radiat- 
ing along the course of this trunk. 

Complicating acetabular fracture may be suggested by crepitus on 
manipulation and ease in reduction. The diagnosis of the presence or 
absence of associated bone lesions should be made by the x-rays. 

The determination as to whether the luxation is iliac or ischiatic is 
dependent rather upon palpating the head of the bone in its abnormal 
position than upon the greater degree of adduction and inversion as 



THE HIP 



627 



compared to flexion and shortening, since the individual case gives 
no standard for such comparison. 

Internal (anterior) luxation, thyroid or pubic, in accordance with the 
position of the head of the bone, is characterized by abduction and 
outward rotation of the flexed thigh. Shortening is trifling or absent 
in the obturator form. The head of the femur is felt in its abnormal 
position, the trochanteric prominence is lessened. 



Fig. 422 



Fig. 423 





Dislocation of hip. (Park.) 



The pubic luxation is characterized by marked shortening, obvious 
groin tumor formed by the femoral head, usually slight or absent flexion. 
If the head of the femur be pushed beneath Poupart's ligament, there 
may be inward rotation. 

Pathological dislocation incident to previous disease of the bone or 
joint is characterized by marked shortening of sudden development, with- 
out obvious traumatic cause, occurring in the course of a hip affection. 
This in itself is diagnostic, fracture being excluded by the .r-rays. Such 
a luxation may occur in consequence of a typhoid arthritis unnoticed at 
the time of its occurrence, because of the adynamic condition of the 
patient, and not detected until convalescence. 



628 THE LOWER EXTREMITY 

Affections of the Bursae about the Hip-joint.— Inflammation of 
the deep trochanteric bursa, if acute, is commonly traumatic or sec- 
ondary to direct or systemic infection; if chronic, is usually tuberculous. 
It is characterized by a tender, fluctuating swelling, at times bilocular, 
placed above and behind the trochanter and exhibiting fairly sharp 
outlines. The thigh is held in abduction, outward rotation, and slight 
flexion. The motions of the hip-joint which do not increase the ten- 
sion of the bursa are free and painless. 

Diagnosis is based upon the position of the tumor, its fluctuating char- 
acter, and its indolence; should it present the consistency of solid growth, 
by excision and examination, since sarcoma may be primary in the bursa. 

Iliopsoas bursitis forms a fluctuating, tender tumor, often bilocular, 
and occasioning severe pain along the course of the anterior crural 
nerve. It may reach the size of a child's head, filling the upper part of 
Scarpa's triangle and making prominent the femoral artery. Extension 
of the thigh on the pelvis is painful, flexion, abduction, and outward 
rotation being the usual position. 

The diagnosis is based upon the position of the tumor, the greater 
prominence and tension on extension of the thigh on the pelvis, and, if 
the walls be so thick as to obscure fluctuation and simulate solid growth, 
by excision and examination. 

Ischiatic bursitis is characterized by a fluctuating swelling over the 
ischiatic tuberosity. It may become acutely inflamed, forming a deep 
phlegmon. The diagnosis is based upon its position. 

Arthritis of the Hip. — Traumatic Arthritis. — Traumatic arthritis inci- 
dent to contusion or sprain is attended by characteristic tenderness to 
deep pressure, pain, limitation of movement, and, in its severe form, 
muscular atrophy. If recovery be not complete and fairly prompt, asso- 
ciated bone lesion should be suspected. Trauma in middle-aged and 
elderly men is often the apparent cause of arthritis deformans. 

Acute Infectious Arthritis. — Acute infectious arthritis of the hip, a 
localization of systemic infection, usually rheumatic or gonorrheal, at 
times typhoidal, influenzal, pneumonic, diphtheritic, scarlatinal, or inci- 
dent to a number of other less common infections, is characterized by 
pain, aggravated by motion, tenderness, fixation, swelling which, because 
of the deep position of the joint, is not immediately demonstrable, and, 
if the infection is actively proliferating and producing extensive destruc- 
tion of tissue as typified by the staphylococcus and streptococcus, the 
symptoms of profound sepsis. 

Gonococcal arthritis is characterized by extreme pain. In the hip-joint 
it is usually of the plastic type resulting in ankylosis. Children are not 
immune against this form of coxitis. 

Rheumatic arthritis, usually polyarticular and migratory, if monartic- 
ular, is diagnosticated as such on the basis of constitutional symptoms 
and on the absence of other recognized infecting causes. 

Typhoidal arthritis is characterized by large joint effusion, with other 
symptoms but slightly marked. Occurring as it does at the period of 
maximum illness, it is often overlooked until luxation calls attention to it. 



THE HIP 629 

Osteomyelitic arthritis is commonly observed in infants and children. 
There is profound sepsis. Joint tenderness and fixation are char- 
acteristic, edematous periarticular swelling develops rapidly, followed 
shortly by softening and fluctuation. There is often epiphyseal separa- 
tion, or necrosis of the head and the neck of the bone. The joint is not 
always involved in trochanteric osteomyelitis. 

Pneumococcal arthritis also occurs at or shortly after the period of 
maximum illness. The effusion is commonly suppurative and the 
symptoms acute. 

Traumatic arthritis or any of the acute infections may become chronic. 
Other forms of arthritis begin insidiously and are chronic from the start. 
Tuberculous arthritis is the most conspicuous example of this class. 

Tuberculosis of the Hip-joint. — Tuberculosis of the hip-joint, com- 
monest in children after the second and before the tenth year, rare in 
infants and adults; usually begins in or near the epiphyseal line of the 
femoral head; it may be synovial or acetabular in onset. 

Tuberculous heredity or disease in other parts of the body is a pre- 
disposing factor. It may develop in children w^ho apparently are per- 
fectly well. The first symptom is usually an intermitting limp, usually 
attributed to slight trauma. Pain, which is also intermittent, is often 
referred to the knee, and as the disease progresses it is marked by recur- 
ring brief nocturnal paroxysms causing the typical night cries. 

Examination in the early stage shows limitation in the joint move- 
ments due to muscular spasm, tenderness, muscular atrophy, and possi- 
bly trochanteric thickening. 

Limitation of movement is the most important single diagnostic sign 
of arthritis. Slight motions may be free and unimpeded, but the full 
movement of the joint is always arrested, and usually in all directions, 
though the Hmitation is most pronounced in the direction of extension. 

Atrophy is evidenced in both the thigh and gluteal muscles; at times 
it can be demonstrated by measurement before it is obvious to inspec- 
tion. Partly because of this atrophy, but mainly on account of the 
slight flexion in which the joint is customarily held, the gluteal fold is 
less marked than on the sound side. 

In the early stages the thigh is slightly flexed, rotated outward and 
abducted, and while walking during the limp periods the ankle of the 
affected side is extended and the knee flexed to save the joint from jar. 

Direct examination in the early stages has for its end the detection 
of limited motion, of tenderness, of muscular atrophy, and trochanteric 
thickening. The garments must therefore be so arranged that the lower 
part of the body, the pelvis, and the lower extremities can be seen and 
the two sides compared. With the patient in dorsal decubitus, the legs 
are brought together, as nearly as possible parallel with the long axis of 
the body; if one thigh be fixed in abduction, this is only possible by 
lateral tilt of the pelvis, hence a line drawn from one anterior iliac spine 
to the other will not make a right angle with the midline of the trunk. 

The limb of the sound side is grasped by the ankle, and with the other 
hand resting upon the ilium to detect any movement in it, the knee is 



630 



THE LOWER EXTREMITY 



flexed upon the thigh, and the thigh upon the pelvis to the fullest extent; 
thereafter motions of abduction, adduction, and rotation are practised. 
A similar examination is then conducted with the leg and thigh of the 
affected side, the hand on the ilium noting the moment when this bone 
participates in the thigh movements. The motion is usually limited 
by an elastic resistance (muscular) in all directions, but particularly 
in extension and adduction and internal rotation. 





Fig. 424 




^^^;^ 




^^^^ 



Subacute coxitis Hip-joint held in position of flexion, aversion, and abduction. Eversion is 
indicated by the outward rotation of the foot and flexion by the lordosis in the lumbar spine during 
full extension of the thigh. Compare with Fig. 425. (Carnett.) 



Fig. 425 




Subacute coxitis. Same patient as in Fig. 424. The degree uf flexion deformity at the hip- 
joint from spasm of the iliopsoas is indicated by the extent to which the thigh must be flexed to 
abolish the lumbar lordosis. (Carnett.) 



To detect the slight flexion, an invariable early symptom of coxitis, 
with the patient in dorsal decubitus, the sound limb is flexed until the 
knee touches the chest. If no flexion exists, the popliteal space upon 
the affected side can be made to touch the table. Both thighs are flexed 
until the small of the back lies flat on the table. The thigh and knee of 
the sound side are then extended until the popliteal space is in contact 
with the table surface. An effort to place the affected limb in the same 
position is immediately followed by arching of the lumbar spine. 



THE HIP 631 

The test for limited extension is applied by placing the patient in 
ventral decubitus and lifting the straight legs from the table, the pelvis 
being held down. In a healthy child the hip-joint can be hyperextended 
until it makes an angle of about 10 degrees with the surface on which 
the child lies. 

The circumference of both thighs is measured for muscular atrophy 
at the same point, usually just below the gluteal fold, the limbs being held 
in exactly the same position for this measurement. 

Tenderness is elicited by palpation anteriorly and posteriorly, by 
jarring the trochanter, by flexing the leg at the knee and jarring the end 
of the femur with the ball of the hand. This sign usually has been 
sufficiently demonstrated beforehand in the examination for limitation 
of motion. 

Trochanteric thickening is detected by palpation and comparison 
with the trochanter on the unaffected side. 

These symptoms, if present, simply prove that the hip-joint is 
inflamed. 

The tuberculous nature of this inflammation is suggested by the age 
of the patient, the absence of adequate cause, and particularly by the 
slow but progressive evolution. The tuberculin test is corroborative 
and the a::-ray findings are at times, in themselves, diagnostic, both as 
to the nature of the affection and its seat. 

Sprain or contusion of the hip-joint, or sprain or rheumatic myositis 
of the iliopsoas muscle, exhibit similar symptoms. There is usually 
an adequate cause, and recovery is prompt and complete under appro- 
priate treatment. 

The joint irritation incident to an unrecognized epiphyseal separation 
or partial fracture of the neck of the bone, in the absence of shortening 
sufficient to be demonstrated by measurement, can be distinguished from 
tuberculous arthritis following trauma only by the a:-rays. 

In lumbar Pott's disease, among other symptoms, there will be pain, 
limp, and muscular fixation of the leg in much the position characteristic 
of coxalgia. Fixation is, however, only against extension, other move- 
ments being free, the hip-joint is not tender, and the spinal seat of the 
trouble is readily determined if search be made for it. The two con- 
ditions are sometimes associated. 

From coxa vara, the distinction is suggested by the different age inci- 
dence, the slower progression of symptoms, the elevation of the greater 
trochanter in the absence of the evidence of extensive bone or joint 
involvement, and the findings of the or-rays. 

Acute epiphysitis of infancy and childhood is characterized by violent 
onset, rapid course, and early and free pus formation. 

In sacro-iliac disease the thigh and leg are carried straight, there is 
tenderness over the sacro-iliac joint, and all hip motions are free, except 
those which throw a strain directly upon the sacro-iliac joint. 

Hysterical joint is marked by an incoordination and irregularity of 
symptoms, with pain dominant, and is associated with other signs of 
hysteria. Moreover, the age incidence is different. 



632 THE LOWER EXTREMITY 

In cases of referred pain the joint movements are free. 

Chronic arthritis, secondary to subacute or chronic osteomyelitis 
in its development and progress, closely simulates tuberculous arthritis. 
Recovery may take place without suppuration, but with both deformity 
and disability. Usually abscesses form, discharging for months or years. 
Healing is followed by recurrence of inflammation. The differential 
diagnosis is dependent upon bacterial examination, including animal 
inoculation and the tuberculin test. 

Arthritis Deformans .^ — Arthritis deformans, exceptionally observed in 
young people and then secondary to trauma, usually developing spon- 
taneously in persons past forty, is characterized by pain usually attrib- 
uted to sciatica, limp most marked after rest, limitation of motion, 
muscular atrophy, joint crepitus, cartilaginous erosion, bony outgrowth 
demonstrable by the a:-rays long before they can be palpated externally, 
and elevation of the trochanter of the affected side. Early diagnosis 
is suggested by limited abduction and abnormal elevation of the tro- 
chanter, and is confirmed by the ir-rays. 

Tabetic Arthropathy. — Tabetic arthropathy of the hip-joint, at times 
an early symptom of tabes, is characterized by pronounced swelling of 
rapid development due to sudden effusion into the joint, without pain, 
markedly increased disability, or other symptoms of inflammation. Later 
there is destruction of joint surfaces, at times spontaneous luxation. 

Syringomyelia produces similar changes. 

Tumors of the Hip. — These, with the exception of the superficial 
lipomata and the exostoses and chondromata, which may grow from 
either the pelvic bones or the femur, should be regarded as malignant 
unless they have been existent and stationary for such a long period as to 
make the assumption improbable. 

The early diagnosis should be made by the a;-rays. These should 
be employed when there is complaint of persistent, deep-seated, localized 
bone pain in the absence of joint involvement. In case of doubt, with 
the seat of lesion indicated by the rr-rays, the diagnosis should be by 
operation. 

Huge tumor, rapid growth, dilated superficial veins, and eggshell 
crackling are symptoms highly characteristic, but too late, as a rule, to 
be of service to the patient. 

Thick-walled bursse and subaponeurotic lipomata should be diagnos- 
ticated as such by removal. 

Hysterical Joint. — Hysterical joint may closely simulate organic dis- 
ease, since pain, tenderness, swelling, heat, and muscular contraction 
may all be present. Pain and tenderness are out of proportion to 
the findings. There is a lack of consistency in the symptoms, and 
contractions disappear under etherization. Moreover, there is a history 
of other hysterical seizures and other unmistakable symptoms of this 
condition. The contraction usually involves the adductors and internal 
rotators. It may be entirely involuntary. 

Snapping hip, by which is meant the power of partly displacing the 
hip upon the upper border of the acetabulum, may become habitual. 



THE BUTTOCKS 633 



THE BUTTOCKS. 

Either wound or contusion of the buttocks may be followed by a deep 
extravasation of blood incident to partial or complete rupture of the 
gluteal, the pudic, or the sciatic artery. This may result in the forma- 
tion of a progressive, fluctuating, painful tumor which, even though it 
present neither thrill nor bruit, is necessarily due to hemorrhage because 
of its rapid (hours) development. 

When the blood extravasation is more gradual and more efficiently 
limited by inflammatory reaction of the surrounding soft parts, the 
resultant traumatic aneurysm may exhibit the tenderness, pain, and rate 
of growth which would be characteristic of a deep infected thrombus. 
Pronounced constitutional symptoms are absent, and thrill and bruit 
have usually been present, together with severe pain incident to nerve 
pressure. In the absence of characteristic aneurysm symptoms, a pre- 
vious history of trauma should suggest the possibility of aneurysm. 

The distinction from cold abscess pointing backward, or from gluteal 
hernia, may be impossible without direct exploration. Both the trau- 
matic and idiopathic gluteal aneurysm may be first suggested by severe 
sciatic pain before the development of a palpable pulsating tumor. 

Gluteal Hernia. — Gluteal hernia (rare) forms a tumor which may be 
partly or wholly reducible, and may be resonant. It is rarely detected 
until it projects beneath the gluteus maximus into the perineum or until 
symptoms of strangulation or incarceration are accompanied by pain 
and tenderness in the region of the sciatic notch, with possibly pressure 
pain radiating down the leg. 

Abscess. — Abscess centring in the gluteal region may originate from 
iliac or sa cro-iliac osteomyelitis or from postperitoneal or purulent collec- 
tions, or those of spinal origin. The diagnosis is usually based upon the 
symptoms of the original infection. In the absence of these it may be 
difficult. 

Sarcoma. — Sarcoma originating in the soft parts of the buttocks is 
rare. Diagnosis should be formulated by the immediate removal of a 
tumor not obviously benign. 

Sacrococcygeal Tumors of Congenital Origin. — A hernial protrusion of 
the dura may occur at the coccygeal junction, often associated with 
lymphangiomatous or teratomatous growth. The latter are common 
in this region as are also dermoids which may be simple or compound 
implantation cysts, and sarcomata. 

The congenital tumors of the coccyx grow downward rather than 
upward, lymphangioma and teratoma complicating meningocele on the 
dorsal surface of the coccyx; whereas teratomata, congenital lipomata, 
and cystic lymphangiomata are found in front of the coccyx, lying 
between this bone and the rectum, and exhibiting no dural connection 
(Steinthal). 

The diagnosis of these tumors is based mainly on their congenital origin. 

The dermoid placed over the coccyx or lower portion of the sacrum 



634 



THE LOWER EXTREMITY 



in the midline is fairly common. It usually excites no attention until it 
becomes inflamed. Suppuration is followed by a persistent midline 
sinus, usually mistaken for rectal fistula. Diagnosis is made by probe, 
often by the finding of hair in the discharge. 

Anterior sacral meningocele (rare), forming a tumor detected by rectal 
palpation, may be recognized by the bony defect shown by the x-rays, and 
by aspiration and examination of the fluid. 

Dermoids in the pelvic connective tissue are usually not recognized as 
such until operation. They may remain latent until adult life. 



Fig. 426 




Syphilodermic tubercle. Closely resembling lupus vulgaris 



Coccygodynia is a term applied to pain greatly aggravated by move- 
ments of the coccyx such as are incident to sitting down, defecating or 
coughing, and reaching its maximum intensity incident to direct palpa- 
tion. It may be due to an arthritis, a neuritis, a chronic osteomyelitis, 
or be without assignable cause. It frequently follows traumatism. It 
is often simulated by the hysterical. 

The pubic joint may be congenitally absent, the pubic bones being 
widely separated from each other. This is a common complication of 
exstrophy of the bladder. The motion of this joint is a vertical sliding 
one. The strong iliosacral joint allows the ilium to tilt slightly. 

Disjunction of the pubic symphysis, necessarily accompanied by sprain 
or fracture of the sacro-iliac joint, is characterized by local pain, tender- 
ness, mobility, tumor from blood effusion, frequently urethral tear, 
indicated by bleeding from the meatus, and retention of urine. There 



THE BUTTOCKS 635 

Is usually history of adequate trauma. Urinary retention is an almost 
constant accompaniment of severe pelvic injury in the absence of urethral 
rupture or bladder lesion. 

Strain of the sacro-iliac joint incident to sudden violence, either muscular 
or jarring, is characterized by local pain, exaggerated by lateral pressure 
upon the pelvis, direct palpation, or standing, jarring on the heels, and 
motions of the thigh which impart motion to the joint, as does flexion of 
the thigh with straight legs. Recovery is usually prompt. Symptoms 
incident to inadequate treatment may become chronic, a condition of 
traumatic arthritis developing. 

Fractures of the Pelvis. — By direct impact the crest of the ilium or 
either of the anterior spines may be broken, the latter possibly by muscular 
force. The diagnosis in the absence of preternatural mobility and 
crepitus is suggested by persistent deep tenderness, and is corroborated 
by the .x-rays. 

Deep fractures, incident to crushing force, acting either antero- 
posteriorly or laterally, usually involve the pubic bone, the break passing 
through both the upper and the lower ramus and from above down- 
ward and inward; sometimes extending into the acetabulum. This 
fracture may be comminuted, bilateral, may be complicated by a fracture 
of the ilium passing from its crest to the sciatic notch or one at its junc- 
tion with the sacro-iliac articulation, or more frequently by a fracture of 
the sacrum paralleling the articulations. 

The diagnosis is made by palpation, since obvious deformity is usually 
absent. Mobility and crepitus may often be detected by external 
palpation of the accessible surfaces, supplemented by lateral pressure 
upon the iliac crests from without inward and by separating them by 
force exerted upon the anterior superior spines in the outward direction. 
This manipulation in case of fracture always occasions pain, often 
referred in its greatest intensity to the sacro-iliac joint, which is necessarily 
sprained even though there be no fracture near it. 

External examination should be supplemented by rectal palpation, by 
means of which the posterior portion of the pubic bone and its rami can 
be felt. 

As a result of break in the continuity of the pelvic girdle there is com- 
plete disability, always persistently localized tenderness aggravated by 
motion, frequently rupture of the urethra and bladder, characterized by 
either the inability to pass water or the passage of bloody urine and late 
discoloration, which if it appear above Poupart's ligament is regarded 
by Rose as of diagnostic importance in distinguishing between intra- 
capsular fracture of the neck of the femur and fracture of the acetabulum. 

When diagnosis of fracture of the pubic bone is established, the integ- 
rity of the urethra and bladder should be assured by catheterization, 
unless the patient be able to void urine unstained by blood. 

Osteomyelitis of the Pelvis. — Osteomyelitis of the pelvis may occur in 
the acute or chronic form, may be diffuse or circumscribed. 

Acute diffuse osteomyelitis of the ilium commonly involves both the hip 
and the sacro-iliac joints, and is attended with symptoms of violent sepsis. 



636 THE LOWER EXTREMITY 

In its circumscribed form the affection is often subacute or chronic, 
and invades the acetabular region in young children, the region of the 
crest and spine in older ones. 

Acute osteomyelitis of the sacrum usually spares the sacro-iliac joint. 

The sudden onset of symptoms of virulent constitutional infection 
associated with deep pain, often referred to the hip-joint, and tender- 
ness are in themselves suggestive. Edematous swelling and abscess 
formation are the signs on which diagnosis usually is based. If the pro- 
cess be not diffuse, there may be a subsidence of constitutional and local 
symptoms followed (weeks or months) by the appearance of a fluctuating, 
non-inflammatory tumor due to pus. Such cold abscesses may form 
as a sequel of osteomyelitis chronic from the first and unattended with 
marked constitutional or local symptoms. 

The abscess of iliac, sacro-iliac, or acetabular origin, if it gravitates 
anteriorly, forms a palpable, often fluctuating tumor closely attached to 
the bone and partly filling the iliac fossa. It points either just beneath 
the outer part of Poupart's ligament or lower down the thigh, to either 
side of the sartorius muscle. Posterior pointing may be in the gluteal, 
anal, perineal, or upper posterior thigh region. 

Subperitoneal abscesses usually secondary to lesions of the cecum, 
appendix, bladder, prostate, or seminal vesicles point usually above 
the inner third of Poupart's ligament or through the saphenous opening. 
Psoas abscess points below Poupart's ligament and to the outer side of 
the bloodvessels. 

Traumatic inflammation of the sacro-iliac joint, characterized by pain, often 
referred to as a backache, located in the sacral region, and sequent on 
slight injuries or overuse, or long maintenance of a position which renders 
the ligaments tense, is diagnosticated by tenderness in the joint elicited by 
hyperextension of the thigh on the pelvis, by attempting to extend the 
leg on the flexed thigh, by directing the patient to bend forward with the 
knees straight, by all motions which render tense the muscles of the ham, 
and thus tilt the ilium. 

Sacro-iliac inflammation, usually tuberculous in nature, and resulting 
in abscess formation, is rarely observed in children, nor is it common 
at any age. Its characteristic initial symptom is pain referred to or 
near the joint, radiating over the buttock and down the back and inner 
part of the thigh to the knee, so greatly aggravated by movement as to 
be crippling in intensity, accompanied by a sense of weakness about 
the joint, with a distinct limp on walking; the body being inclined to 
the sound side, with apparent elongation of the affected leg incident 
to the lowering of the pelvis on that side. 

The diagnosis is based upon direct examination. With the patient in 
dorsal decubitus, squeezing the pelvic brims together or separating them 
may give pain. In ventral decubitus the joint is tender to deep pressure, 
hyperextension of the thigh on the pelvis is limited and painful, the leg 
cannot be straightened on the flexed thigh, and bending forward is 
painful. 

Swelling and abscess formation ultimately develop and may be 



THE BUTTOCKS 637 

detected either externally over the joint or by rectal palpation, though 
the pus may burrow forward beneath the sheath of the iliacus muscle 
and point in front without being accessible to the rectal touch. When 
the abscess breaks into the rectum or opens into the rectal fossa its track 
can usually be traced either by probing or by the injection of iodoform 
or bismuth and making a picture with the a;-rays. 

The diagnosis of the tuberculous nature of the affection depends upon 
the results of the tuberculin test and laboratory examinations of the 
discharge when sinuses have formed. 

The distinction from disease of the hip-joint is made by noting that 
when the pelvis is fixed all motions of the hip-joint are free except such 
as put some strain on the sacro-iliac articulation. 

In the early stages the elimination of low Pott's disease is difficult. 
The latter condition is the usual one in children. 

A chronically inflamed appendix may produce precisely the referred 
and local pains of sacro-iliac disease, the differential diagnosis being 
based upon the absence of distinct tenderness over the joint, the presence 
of appendix tenderness, and the associated gastro-intestinal symptoms 
of appendicitis. 

From sciatica the affection is distinguished by the existence of local 
tenderness in the joint. 

Rheumatism, gonorrhea, syphilis, and other forms of infection may 
manifest their presence by chronic inflammation in or near the sacro-iliac 
joint. 

Exostoses originating in the pelvic bones are usually found about the 
sacro-iliac articulation, and exhibit their characteristic slow growth. 
They occasionally develop on the outer extremity of the acetabulum, in 
which case they may interfere with motion, and if traumatized may 
undergo sarcomatous degeneration. The diagnosis is by palpation, by 
pressure symptoms, expressed particularly in the form of sciatica, and 
by the a;-rays. 

Chondromata (rare), noted about the iliosacral joint and the pubic and 
sciatic rami, are symptomless except for their bulk and the pressure symp- 
toms they may produce. The diagnosis is based upon the detection of a 
dense, distinctly nodular tumor which gives no rr-ray shadow. It is cor- 
roborated by removal. 

Sarcoma, either of the periosteal or central type, is usually found in 
the ilium to the outer side of the vessels, and is characterized by its rapid 
growth, early development of pressure symptoms, often by pulsation. 
Diagnosis should be made by the a:-rays and by prompt removal. Huge 
tumor, venous obstruction, eggshell crackling are late signs. 

Pressure symptoms are usually first manifested in the form of pain, 
which may be sudden in onset, relieved by position, and becomes pro- 
gressively worse with the growth of the tumor. Since there may be 
associated with a rapidly growing tumor a distinct fever with pronounced 
anemia, the disease may closely simulate a subacute or chronic osteo- 
myelitis. The distinction can usually be made by the a:-rays. 



638 THE LOWER EXTREMITY 



THE INGUINAL REGION AND GROIN. 

The surgical affections peculiar to this region are displaced testicle 
and affections of the spermatic cord or the round ligament. 

Affections common in this region are hernia, inflammatory and neo- 
plastic glandular enlargements, varicosities of the lymphatics or blood- 
vessels, aneurysm, and tumors or cysts. 

Undescended or misplaced testicle forms an oval, smooth, usually 
movable, tender nodule. Its nature is suggested by the absence of the 
gland from its normal position. It is subject to recurring inflammation 
and malignant degeneration, and is often complicated by hernia (see 
p. 504). 

Hydrocele of the cord, an affection of infants, forms a fluctuating 
non-inflammatory, non-sensitive, translucent tumor, moved by traction 
on the testicle. It may be partly or wholly reducible. The distinction 
from lipoma (rare) or non-reducible epiplocele may be difficult, since 
the latter in infants exhibits a moderate degree of translucency. 

Hydrocele of the round ligament exhibits a slightly mobile tumor in 
the inguinal canal, partly reducible, presenting, if large, through the 
external ring. It may be partly reducible. It is occasionally so closely 
simulated by a cold abscess originating from the pubic bone that differ- 
ential diagnosis is made only on operation. 

Hernia is the usual cause of inguinal swelling. Its complete reduci- 
bility and the palpation of an empty inguinal or femoral canal there- 
after constitute the chief diagnostic features. 

Obturator hernia, an affection of old women, if it gives diagnostic 
symptoms, will be characterized by a swelling to the inner side of the 
bloodvessels, and pain radiating along the course of the obturator nerve 
and involving both the hip and the knee. Careful palpation is needful 
to make the distinction from femoral hernia. 

Gravitation abscesses are reducible and exhibit impulse on coughing. 
These may be of spinal, sacro-iliac, pelvic, or prostatic origin. 

Cold abscesses of spinal origin form a fluctuating tumor to the outer 
side of the bloodvessels below Poupart's ligament. By abdominal 
palpation the tumor can be traced upward along the course of the psoas 
muscle, and through fluctuation can be elicited. 

Cold abscess of sacro-iliac or iliac origin usually points in the outer 
part of the groin below Poupart's ligament. 

An abscess forming as a result of subacute or chronic osteomyelitis 
of the pubis may readily simulate in position and symptomatology an 
omental hernia. 

Postperitoneal cysts, extravasations, or inflammatory collections (see 
p. 492), if large, may point on the inguinal region or groin, as does a 
psoas abscess. 

Inflammation of the lymphatic glands of the groin, if there be no 
demonstrable focus on the skin surface drained by them, should suggest 
anal and urethral examination. The inflammation incident to ordinary 



THE INGUINAL REGION AND GROIN 639 

infection may be hyperplastic or suppurative, and is readily recognized. 
That incident to chancre exhibits characteristic bilateral polyglandular, 
painless enlargement (see p. 643). 

Chancroidal adenitis frequently suppurates and leaves persistent bur- 
rowing sinuses incident to reactionary inflammation against the necrotic 
gland substance. 

Tuberculous adenitis, by no means uncommon in this region, exhibits 
the chronic course and progressive involvement of the entire superficial 
group with deep extension, tendency to softening and to sinus formation, 
and ultimate generalization characteristic of the infection in general. 

The diagnosis is based upon the tuberculin test and animal inoculation. 

Carcinoma involving the inguinal glands is always secondary. 

Lymphosarcoma is marked by rapid and apparently causeless growth, 
without inflammatory symptoms and exhibiting a tendency to become 
adherent to neighboring structures. The diagnosis should be made by 
immediate removal. 

The enlargements noted in Hodgkin's disease are associated with 
similar growths elsewhere. 

The cystic tumor of the lymphatic gland due to the filaria develops in 
the superficial inguinal group. The diagnosis is based upon associated 
dilatation of the afferent lymphatic vessels and the finding of the parasite 
in the blood. 

Lymphangioma may be difficult to distinguish from lipoma unless 
individual varices can be felt. It is usually indefinite in outline, some- 
what nodular, and often congenital. 

Hemangioma is usually associated with dilated skin vessels which 
suggest the diagnosis. Its size variation incident to position is charac- 
teristic. 

Aneurysm is usually unmistakable. Even when inflamed, and with a 
sac so extremely laminated that expansile pulsation is not present, a care- 
ful examination and a study of the history of the case usually enables a 
correct diagnosis to be formulated. 

Tumor of the soft parts which is not surely recognized as benign 
should be diagnosticated as to nature by immediate operation. 

Exostoses of pelvic origin may become palpable in the groin. Dense 
consistence and slow growth suggest the diagnosis which is corroborated 
by the a:-rays. 

Sarcoma of the pelvic bones may first become manifest by groin tumor, 
less dense in structure than either chondroma or osteoma, and more 
rapid in growth. Diagnosis is made as by the .T-rays. 



CHAPTEE XVIII. 

THE GENITO-URINARY ORGANS. 

The symptoms of surgical affections of the genito-urinary organs are 
visible or palpable alteration in position, size, or conformation, one or 
all; disturbance of function; pain either localized or referred; and blood 
or purulent discharge or both, appearing externally from a sore or sinus, 
discharging from the urethra when the anterior part of the mucous 
passage is involved or found in the urine v^hen the lesion involves any 
portion of the urinary tract in or behind the membranous urethra. 
In addition there may be constitutional symptoms incident to deficient 
elimination or septic absorption. 



THE PENIS. 

Congenital Malformations. — This organ may be absent, in which 
case the urethra opens into or near the anus, concealed, but discoverable 
by palpation. It may be minute, even of quill size, gigantic, double, 
twisted, or adherent. These rare deformities are obvious. The com- 
mon deformities are those associated with urethral defects (see p. 666). 

The prepuce may be deformed, absent, adherent, or redundant; excep- 
tionally with an orifice so small as to constitute a source of urinary obstruc- 
tion. It is usually redundant and adherent at birth. The frenum may 
be so short as to interfere with erection. 

Trauma of the Penis. — Contusion is characterized by rapid swelling 
and discoloration. Blood from the urinary meatus indicates partial 
or complete rupture of the urethra. 

Wounds. — ^ Wounds are of importance in accordance with whether the 
urethra and the erectile tissue are or are not involved. 

Fracture. — Fracture of the penis due to traumatism exerted upon the 
erect organ is due to a tearing of the fibrous investment of the erectile 
tissue. It is attended by severe pain, rapid swelling, and subsidence of 
erection. Prognosis as to function without operation must be guarded. 

Dislocation of the Penis. — ^As the result of great force the penis may 
be squeezed from its skin investment as a grape from its skin. The 
sheath of the penis is filled with blood clot closely simulating the flaccid 
organ. 

This rare injury is usually complicated by rupture of the urethra. If 
it be suspected the foreskin should be retracted until the head of the penis 
is brought clearly in view. This is always necessary after severe trauma 
of the penis to determine the presence or absence of urethral rupture. 



THE PENIS 641 

Inflammatory Affections of the Penis. — Diffuse Inflammations. — The 
envelopes of the penis are, aside from distinctly venereal disorders, subject 
to diffuse inflammations observed in other parts of the body, such as 
dermatitis, particularly that from rhus poisoning, eczema, pruritus, 
urticaria, erythema intertrigo, stings of insects, erysipelas, lymphangitis, 
diffuse cellular inflammation, and gangrene. 

Rhus dermatitis is suggested by the history of exposure and sudden 
and rapid spread of the vesicular eruption. 

Eczema is a rebellious affection usually involving both the scrotum 
and the penis; gradual in onset, spreading slowly, and exceedingly 
persistent. 

Pruritus and erythema intertrigo more commonly attack the scrotum. 

Urticaria. — In the absence of previous lesion a pronounced, rapidly 
formed (hours), edematous swelling, involving the skin and subcutaneous 
tissues, not interfering with the function of urination except by edematous 
phimosis, and not spreading peripherally, is likely to be urticarial (acute 
rheumatism, gastro-intestinal disturbances). 

Erysipelas. — If an acute swelling has been preceded by surface 
lesions such as those of balanoposthitis, and it exhibits a tendency to 
spread from the root of the penis over the abdomen and thighs, particu- 
larly if it is associated with the constitutional symptoms of septic absorp- 
tion, has raised borders, and is accompanied by enlargement of the 
inguinal glands, the affection is probably erysipelas. 

Cellulitis. — If the swelling has been preceded by difficulty in micturi- 
tion and induration along the course of the urethra, and in its progression 
involves the penis, the scrotum, and thence spreads directly upward on the 
abdominal walls, sparing the anal perineum and upper part of the thighs, 
urinary extravasation should be suspected and examined for. 

Cavernitis. — If the swelling is associated with marked .deep induration 
and profound constitutional symptoms of septic absorption, involve- 
ment of the erectile tissue should be suspected, usually secondary to 
extravasation. When the inflammation has proceeded to gangrene the 
diagnosis is sufficiently obvious. 

Lymphangitis in its acute form is always secondary to an infected lesion, 
and is characterized by an edematous swelling of the skin of the penis 
and the presence of an indurated tender cord in the position of the dorsal 
lymphatic vessels, movable with the skin over the deeper parts. The 
inguinal glands are enlarged. Small dorsal abscesses may form. 

Phlebitis (rare) is attended with symptoms characteristic of lym- 
phangitis, except that the induration is more deeply placed and the 
inguinal lymphatic glands are not necessarily enlarged. 

Circumscribed inflammation of the penis may be non-ulcerating or 
ulcerating. 

The non-ulcerating inflammatory circumscribed lesions of the penis are 
itch, papular syphilitic eruptions, exceptionally chancre, and paraphimosis. 
With the exception of the chancre, lesions of a similar nature on other 
parts of the body suggest the diagnosis, though itch may occur only on 
the penis. The detection of the burrow under a magnifying glass and 
41 



642 THE GENITO-URINARY ORGANS 

the finding of the insect or the effect of sulphur treatment would be 
conclusive. 

When chancre appears as a papule which does not ulcerate, a history 
of exposure to infection not less than twelve days before the appear- 
ance of the lesion, the development of induration (five days), inguinal 
adenopathy, and resistance to treatment should suggest a diagnosis 
which could be formulated by excision and microscopic examination of 
the papule. 

Paraphimosis, characterized by edematous swelling of the foreskin 
beyond the ring of constriction formed by a tight preputial orifice drawn 
behind the glandular corona is usually obvious on inspection. Excep- 
tionally the prepuce, in place of turning back as the sleeve of a coat, 
and causing edema of its mucous surface, slips directly over the corona 
and causes rapid swelling of the glans. In such a case the ring of con- 
striction may be picked up by a grooved director passed from before 
backward in the sulcus. When the prepuce is rolled back the constriction 
ring must be picked up by the director passed from behind forward. 

Eroded or ulcerating circumscribed inflammatory lesions of the penis 
include balanoposthitis, simple hair cuts or abrasions, herpes, chancre, 
secondary and tertiary lesions of syphilis, chancroid, tuberculous ulcera- 
tion, and epithelioma. 

The commonest of these lesions are those of balanoposthitis and simple 
infection from slight trauma. In private practice chancroid is less 
frequent than are the syphilitic lesions. Tuberculous lesions are 
exceedingly rare. 

Paraphimosis in its advanced stage may be attended with deep ulcera- 
tion at the point of constriction or even extensive gangrene of the glans 
and foreskin. 

Balanoposthitis, predisposed to by a long, tight prepuce, the gouty or 
rheumatic diathesis, and abnormal conditions of the urine, often excited 
by a urethral discharge or one from an ulcerating lesion of the glans or 
prepuce, is characterized by itching, heat, swelling, and an offensive, 
irritating discharge. The slightly edematous prepuce, being stripped 
back, shows areas of denudation covered with a thick, creamy discharge. 
There may even be distinct excoriations and superficial ulcers. These 
lesions may be the starting point of lymphangitis, phlebitis, or cellulitis. 
They often precede the development of condylomata. 

This is a common inflammation in children and in adults who do not 
keep the preputial sac clean. 

The inflammation may be a manifestation of secondary syphilis, in 
which case there will be other signs of the constitutional disease, nor will 
cleansing treatment avail. 

Chancroid may begin as a balanoposthitis. The diagnosis can be 
made only by the further development of the latter lesion. The distinction 
from herpes is dependent upon the beginning of the latter in the form 
of discrete vesicles which become confluent with circinate borders. 
These lesions may be, however, quickly complicated, often completely 
obscured, by balanoposthitis. 



THE PENIS 643 

In the presence of phimosis the diagnosis of simple balanoposthitis 
may be extremely difficult. The absence of the gonococcus excludes 
gonorrhea; of induration probably, but not certainly, chancre; prompt 
yielding to cleansing treatment, chancroid. 

If the inflammatory symptoms are persistent or progressive, incision 
will be needful for the framing of a diagnosis. 

Cracks, fissures, hair cuts, and abrasions contaminated by the ordinary 
pus organisms represent the commonest form of genital sores. These 
become obvious within twenty-four hours of the time of infection. Symp- 
toms of local inflammation increase for two or at most three days and 
then rapidly subside under ordinary cleansing treatment. On this 
point the early diagnosis from chancroid and chancre must be made. 

From herpes these simple infections are distinguished by the fact that 
they do not appear first as vesicles or superficial round sores. They 
conform in shape to the original lesion, usually a scratch or hair cut or 
an irregular abrasion. 

Herpes is characterized by the somewhat sudden appearance of vesicles 
with erythematous bases situated on the mucous or skin surfaces of the 
penis. They are attended with itching and burning and are prone to 
recur. They are commonly found about the coronary sulcus, involving 
both the glans and foreskin. The vesicles are quickly macerated, leaving 
round or irregular erosions tending to become rapidly confluent. There 
is associated surrounding balanoposthitis. At times there is intense 
pain, which may be accompanied by urethral discharge because of 
similar lesions in the urethra. 

Herpes is characterized by its tendency to recur, sudden appearance 
in clusters of vesicles, usually in the absence of obvious cause, absence 
of induration, superficial nature of the eruption, circinate border of the 
confluent lesion, and rapid healing of the outbreak under cleansing 
treatment, though fresh crops may appear. There is often bilateral, 
polyglandular, inguinal induration. 

Exceptionally chancre begins as herpes. The diagnosis must be 
based upon the persistence of the original lesions, the tendency to 
induration, and microscopic examination. 

Chancre. — Chancre forms, usually one, often two or more, indolent, 
indurated erosions or ulcerations. Any macule, slight, painless excoria- 
tion, or scratch, which persists in spite of careful local treatment, which 
slowly spreads without marked inflammatory symptoms, which becomes 
distinctly hard peripherally and at the base as though there were a dense, 
cellular infiltrate, and which gives a thin, scanty discharge, showing a 
tendency to crust or to form a pseudomembranous deposit covering the 
excoriated surface, is almost certainly a chancre. 

The diagnosis is further strengthened by proof of exposure, an 
incubation period of two to five weeks, progressive hardening of the 
dorsal lymphatic vessels, and induration of one or more of the inguinal 
lymphatic glands, usually two or three on each side. From mixed 
infection these glands may suppurate. This is exceptional. 

Long incubation, persistent induration, and progressive inguinal 



644 



THE GENITO-URINARY ORGANS 



adenopathy are more characteristic than the form of the lesion, which is 
usually oval or round, but may begin as a balanoposthitis and continue 
as such except for hardening of the foreskin. 



Fig. 427 




Meatal chancre. Incubation, three weeks. Duration, four weeks. Ulcerating surface covered by 
pseudomembrane within the meatus. Inguinal glands typically enlarged. Urination obstructed, 
and occasionally bleeding from the meatus. 

Fig. 428 




Chancre of the glans sulcus and inner preputial surface. The typical induration causes it to 
project in place of lying flat when the foreskin is retracted. Incubation, three weeks. Duration, 
three weeks. A flat, superficial, indolent, rounded sore. Wire-like induration of the dorsal 
lymphatics of the penis. Glands in each groin painlessly enlarged. 



THE PENIS 



645 



The induration may be simulated by the inflammatory infihration 
incident to cauterization of a non-specific sore, or by that of a slowly 
forming furuncle or a folliculitis. A gumma, or so-called relapsing 
chancre, may so closely simulate a primary lesion that differential 
diagnosis must be based upon the history, since both induration and 
inguinal adenopathy may be absent from chancre (exceptional). 

The finding of the spirocheta in the scrapings of an excised sore 
constitutes the only absolutely conclusive early diagnostic sign of chancre. 

Secondary and Tertiary Lesions of Syphilis. — The secondary eruption 
of syphilis, particularly in the form of mucous patch, is common on 
the penis and foreskin. It is usually associated with a recent history 
of syphilis and other unmistakable lesions of the disease. 

Gumma is prone to develop at or near the seat of a former chancre; 
it begins as an induration which softens and discharges, forming a hard, 
indolent, deep ulcer, often mistaken for chancre. The inguinal glands 
are not characteristically enlarged nor do secondary eruptions develop. 



Fig. 429 




Chancroids. Incubation, twenty-four hours. Duration, five da\ s Multiple acutely inflamma- 
tory, freely suppvirating, punched-out destructive lesions. 

Chancroid. — Chancroid usually begins exactly as a simple abrasion or 
hair cut, hence is without incubation, but may not become sufficiently 
obvious to attract attention for three to five days after exposure. The 
lesion may be single and so remain throughout. It is usually multiple 
and successively so, i. e., fresh sores break out in crops. Chancroids 
progress rapidly, forming ragged, punched-out, often undermined, non- 
indurated ulcers, irregular in shape, discharging freely, inflammatory 
in type, covered with a gray, pus-soaked slough or concealed by a thick, 
moist scab. They produce similar lesions on surfaces with which they 



646 THE GENITO-URINARY ORGANS 

come into contact. Their discharge can be inoculated on any portion 
of the surface of the body. In the later stage of their course (three 
weeks) auto-inoculation fails. 

Exceptionally chancroids exhibit induration, particularly those which 
have been cauterized. 

A chancroid may become gangrenous if it be complicated by phimosis 
or paraphimosis, or if it be mechanically or chemically irritated. 

The distinction from simple infection and balanoposthitis is impossible 
if the chancroid be seen at its very beginning. Later it is based upon the 
ulcerating, rapidly extending type of inflammation and the finding of 
the Ducrey bacillus. 

Ulcerating gummata ultimately produce lesions indistinguishable 
in appearance from chancroid. Induration precedes destruction, and 
this process is a matter of weeks or months. 

Tuberculous ulcers are extremely slow, associated with tuberculous 
lesions elsewhere, may exhibit peripherally semitransparent, grayish, 
miliary tubercles, and scrapings show the bacilli microscopically. 

Epitheliomatous ulcer is a common malignant infiltration of the penis, 
usually beginning as a wart in a middle-aged or elderly man, at times 
before the thirtieth year. The mere presence of a persistently (weeks) 
ulcerating wart, not obviously syphilitic, calls for immediate excision and 
microscopic examination. Thus only can the diagnosis be made at a 
time when it is serviceable. 

The well-developed, ulcerating, and fungating epithelioma is unmis- 
takable. Glandular involvement and widespread infiltration of tissue 
will sufficiently distinguish it from broken-down gumma. 

Tuberculous ulcers are rare. They are associated with obvious tuber- 
culous lesions elsewhere, are exceedingly chronic in course, and may 
exhibit about their periphery characteristic miliary tubercles. Finding 
the tubercle bacillus would be diagnostic. 

Abscess of the Penis. — This exceptionally takes the form of an ordinary 
boil. 

Usually it is due to a folliculitis in turn secondary to urethritis. Along 
the course of the urethra can be felt one or more hard, tender, pea-sized 
nodules which usually discharge into the urethra. If the duct leading 
thereto be blocked, the swelling becomes red and soft, and there is an 
external discharge of pus. These abscesses are commonest along the 
course of the bulbous urethra and near the meatus, on one or both sides 
of the frenum. Exceptionally, they give rise to urinary extravasation; 
or opening both internally and externally, form fistulse. In the latter 
case the course of the tract is often indirect, and the urethral opening 
may be in the roof of this canal. 

Tumors of the Penis. — Papilloma. — ^Papilloma is the commonest 
tumor of the penis. It may be single or multiple, confluent or discrete, 
moist or dry. 

Commonly it springs from the coronary sulcus, posterior border of the 
glans penis, margin of the prepuce, the region of the frenum, and the 
orifice of the urethra, and is frequently sequent to urethral discharge 



THE PENIS 



647 



or balanoposthitis. Redundant or phimotic foreskin is the usual pre- 
disposing factor. 

With the condyloma latum, or mucous patch, a wart may readily be 
confounded. The former represents a papillary outgrowth due to irrita- 
tion of the spirocheta or its products. Diagnosis will be based upon the 
history of the case and concomitant lesions. Moreover, the syphilitic 
lesion never attains the enormous outgrowth characteristic of the wart. 



Fig. 430 




Epithelioma of penis. Cauliflower (fungating) mass involving glans and prepuce. One year's 
duration. Edema of dependent portion of prepuce. Bilateral enlargement of inguinal lymph 
glands. (Carnett.) 



Epithelioma. — Epithelioma, beginning as an ulcerating papilloma, is 
diagnosticated by excision and microscopic examination. 

Among rare tumors of the penis may be mentioned sarcoma; der- 
moid, sebaceous, blood, and mucous cysts; horny growths; fibroma; 
adenoma; lymphangioma. These tumors coincide in development and 
appearance with similar lesions placed elsewhere. Cysts of Tyson's 
glands may be multiple and reach a large size. 

Distressing bladder reflexes have been noted in connection with 
angiomata. 

Sarcoma. — Sarcoma, at times melanotic, when originating from the 
glans appears as a rounded nodule, growing from the erectile tissue or 
its sheath, elastic, clearly outlined, increasing rapidly in size, and 
markedly interfering with erection. If gumma can be excluded and 
the small growth from its position cannot possibly be an expression of 
chronic folliculitis, the diagnosis should be made at once by excision 
and microscopic examination. 

Lymphangioma, or elephantiasis, which occurs about the external 
genitals, involves both the penis and scrotum. In this country it is usually 
secondary to disease or removal of the inguinal lymphatics. 



(B48 THE GENITO-URINARY ORGANS 

Dermoid cysts, congenital in origin, usually placed in the raphe, form 
non-inflammatory tumors, which after years of indolence may grow 
rapidly. They are diagnosticated by removal and examination. 

Induration of the Cavernous Bodies. — On the dorsum of the penis 
of middle-aged men may rarely be found on palpation one or more 
irregularly shaped, indurated areas, cartilaginous in hardness, usually 
neither tender nor painful, and causing marked distortion on erection. 
There is no visible tumor, and the overlying skin is freely movable. 
This condition is associated with the gouty and rheumatic diathesis, and 
is distinguished from gumma by its chronicity, its occurrence in the 
absence of signs of syphilis, and the fact that it never breaks down. 

Functional Disturbances of the Penis. — Erection may be absent, 
partial, complete, or persistent. 

Absence of erections may be due to developmental failure, exception- 
ally of the penis, more commonly of the testicles. It is a sequel of 
degeneration or removal of the testes, prolonged priapism, and may 
follow complete prostatectomy. It is a constant, often an early, symptom 
of degenerations of the cord, particularly that of which locomotor ataxia 
is an expression. 

Absent or feeble erections are usually due to a lumbar cord neuras- 
thenia incident to chronic inflammation of the posterior urethra, pro- 
longed, ungratified sexual excitement, sexual excess, or general neuras- 
thenia. The diagnosis is incident to the history and a urethral and 
neurological examination. 

Priapism, or prolonged erection, unaccompanied by sexual desire, 
often painful, may be intermittent or persistent. 

In its intermittent form it is sometimes an early sign of spinal degenera- 
tion. Usually it indicates a source of irritation about the urethra, penis, 
or anus. At times it follows venereal excess. Exceptionally it is appar- 
ently idiopathic, coming on at night, and giving rise to but little incon- 
venience aside from the psychical effect it produces. It is little influ- 
enced by treatment, nor do these cases ultimately develop symptoms 
that would suggest that this recurring priapism is of evil portent. 

Persistent priapism is a common symptom of leukemia, a rare one of 
locomotor axaxia and syphilis of the cord, and a very exceptional sequel 
of perineal trauma. 

The etiology is at times undiscoverable. It may last weeks or months. 
Turgescence is limited to the cavernous bodies, urination is likely to be 
somewhat difficult, and the ultimate result is sclerosis of the erectile 
tissue and incurable impotence. 

THE SCROTUM. 

Congenital deformities are unknown, except in association with other 
lesions of the external genitalia. In hypospadia and hermaphrodism 
there is cleft scrotum. The penis and scrotum may be grown together. 
In the case of undescended testicle the scrotum remains infantile or un- 
developed. 



THE SCROTUM 



649 



Contusions. — Contusions are followed by rapid swelling and intense 
discoloration. 

Edema. — Edema is a common expression of either general vascular 
failure or local inflammation. In the former case it is associated with a 
similar condition elsewhere, and the symptoms of local inflammation are 
absent. Its presence, when not traumatic, or secondary to surface lesion, 
should suggest extravasation of urine. 

Emphysema. — Emphysema, if not artificially produced, is indicative of 
extravasation and extensive sloughing. 

Cutaneous Affections. — These exhibit the characteristics of such lesions 
when placed in other parts of the body. Those of inflammatory nature 
common on the scrotum are erythema intertrigo and eczema; of para- 
sitic nature, pediculosis; of cystic nature, molluscum contagiosum and 
sebaceous cysts. 

Fig. 431 




Eczema rubnun of the scrotum. (Hartzell.) 



Circumscribed erosions or ulcers of the scrotum, if not traumatic, are 
chancre, chancroid, or the lesions of secondary or tertiary syphilis. 

Abscesses and sinuses are secondary to urethral extravasation or simple 
infection, or tuberculous, syphilitic, or malignant degeneration of the 
testicle. 

Cellulitis may be secondary to a wound or granulating surface. It 
is usually an expression of urinary extravasation or abscess rupturing 
into the scrotal tissue. 

Erythema intertrigo is frequent in children and in fat, flabby men, espe- 
cially those who are rheumatic or uncleanly, or both, or who readily chafe. 

Eczema is commonly associated with gout, rheumatism, and diabetes. 
It may occur in any of its forms, causing great itching, burning, and when 
persistent a marked thickening of the scrotal tissues. 



650 THE GENITO-URINARY ORGANS 

Pruritus, most frequently noted in the rheumatic, may develop inde- 
pendently of any local lesion and reach maddening intensity. The only 
symptom is itching, which may produce so great a yearning to scratch, 
pull, and knead the scrotum that decorum, even decency, is forgotten. 

Pediculosis is the usual cause of itching unassociated with pronounced 
skin lesions. 

Diagnosis is made by finding the lice which resemble small skin scabs 
and are most abundant at the root of the penis. The ova, looking like 
flakes of dandruff, but rounded and intimately adherent to the hair, can 
readily be found if search be made for them. 

Fig. 432 




■S*^; 



Elepliantiasi« of scrotum. Ten years* duration. Filaria sanguinis liDmmis never tuuiui, L'liarac- 
teristic thickening and corrugation of the skin. Hyperplasia of the subcutaneous tissues. Pre- 
putial orifice near middle of tumefaction. (Carnett.) 

Molluscum contagiosum is usually seen in children. Small, waxy, 
almost spherical tumors or cysts are found in the superficial layers of 
the skin, mostly sessile, sometimes pedunculated, later they become 
umbilicated, showing a small, black spot in the centre indicating the 
opening into the follicle. They are painless. 

Sebaceous cysts are usually single, forming soft, doughy, rounded 
tumors in the skin. In the adult they may reach the size of an egg 
and are prone to break down and suppurate. 

Chancre, chancroid, mucous patch, gumma, and epithelioma of the 
scrotum exhibit no departure from type. 

Abscess of the Scrotum. — ^Abscess of the scrotum presents characteristic 
features, the edematous swelling being particularly well marked and 
fluctuation occurring early. Except those from a breaking down hema- 



THE TESTICLE AND EPIDIDYMIS 651 

toma or suppurating sebaceous cyst, such abscesses are of urethral, 
testicular, or rectal origin, hence, after discharge, sinuses remain which 
may be multiple or greatly infiltrated. 

Cellulitis of the Scrotum. — ^This, exceptionally traumatic, occasionally 
due to extension of skin infection, is usually a sign and symptom of 
urinary extravasation. The edema is deep and infiltrating, there are 
constitutional signs of infection (exceptionally none), and the preceding 
and accompanying symptoms of urethral obstruction. 

Tumors of the Scrotum. — These, if sebaceous cyst be excepted, 
are rare. 

Epithelioma begins as an indurated wart, which becomes ulcerated, 
scabs on its surface, and is characterized by hard, raised edges, uneven 
surface, and the exudation of ichorous pus. The distinction from syphi- 
litic lesion, when this is in doubt, should be made by excision and 
microscopic examination. 

Lipoma sometimes develops. It may he infiltrating or globular, 
usually the former. Diagnosis is based upon the consistency. Distinction 
from omental hernia may be extremely difficult, indeed quite impossible 
if the tumor has infiltrated alono^ the course of the cord. 

Lymphangioma or lymphedema, usually secondary to inflammation 
or removal of the inguinal lymphatics, and characterized by a brawny 
induration and enormous thickening, may reach huge proportions. The 
diagnosis is obvious. 

Gummata, enchondromata, osteomata, and fibromata are occasionally 
observed. 

THE TESTICLE AND EPIDIDYMIS. 

Congenital Anomalies. — The testicle may be absent, fused, enlarged, 
inverted, arrested in development, imperfectly descended, or displaced 
from its normal position or its track of descent. 

The testicle may be absent on one or both sides. In the latter case 
the diagnosis is based upon impotence and asexuality; hence, it is a 
matter of time. Complete absence of the testes is exceedingly rare. 

The testicle may be arrested at any point in its transit. 

Abdominal Retention. — Abdominal retention may be unilateral or 
bilateral, the testicle may be found close to the posterior abdominal 
wall, below the kidney, may be provided with a long mesorchium, 
allowing it to move freely in the abdominal cavity, or it may be placed 
in the iliac fossa close to the internal ring. 

Inguinal Retention. — The testicle may be arrested at the internal ring, 
in the inguinal canal, or at the external ring, and is usually extremely 
mobile, unless it becomes fixed by attacks of inflammation. 

Cruroscrotal Retention. — In incomplete scrotal descent the testicle lies 
outside of the inguinal canal, but fails to descend completely, being 
found in the fold between the scrotum and the thigh, at a varying dis- 
tance from the ring. 

If the testicle takes an aberrant course, it may be found beneath the 
skin of the abdominal wall at a variable distance from the external 



652 THE GENITO-URINARY ORGANS 

abdominal ring, in the crural region behind the femoral vessels, or 
in the perineum. 

Incomplete transit is most commonly manifested in the form of in- 
guinal retention; the aberrant transit, in the form of perineal ectopy. 

Diagnosis of misplaced testicle is based upon the absence of the gland 
from its normal position and, excepting in abdominal ectopy, the finding 
of it elsewhere. The scrotum is atrophic on the side of the displacement. 
In children the testis is extremely small and very movable, and to the 
unpractised finger not always readily found. The testis which is not 
descended by the sixth year will usually remain in its faulty position 
unless subjected to surgical treatment. 

A testis abnormally placed does not reach full size, nevertheless 
it may secrete healthy spermatozoa unless it be subject to repeated 
inflammation. 

Misplaced testicle is often complicated by hernia of the congenital 
or funicular type exhibiting the characteristic symptoms of hernia. 

Orchi-epididymitis, particularly the traumatic and urethral form, is 
a common complication, exhibiting symptoms which depart from type 
only in their location. Such an affection in the case of abdominal or 
inguinal ectopy might closely simulate internal strangulation of hernia 
and be mistaken for such if absence of the testis were unsuspected, since 
tympany and vomiting are common reflexes of testicular inflammation. 

Torsion is an accident to which the undescended testis seems pecu- 
liarly subject. The symptoms are those of a hyperacute orchi-epididy- 
mitis. Nor can the diagnosis be made with absolute certainty without 
incision. 

Hydrocele and hematocele exhibit symptoms elsewhere described but 
for their unusual position. The congenital hydrocele, slowly reducible 
into the abdominal cavity, must be distinguished from omental hernia 
by marked translucence, slow and gradual reduction, equally slow return, 
and finally by incision. 

Malignant degeneration exhibits a solid tumor in the inguinal region, 
steadily, often rapidly progressive, accompanied by persistent pain. The 
diagnosis must be made through an incision, since, when it is obvious 
from nodulation, great size, and adherence of the tumor, operation is of 
no avail. 

Inversion of the Testicle. — Though it may descend to the bottom of 
the scrotum, the testicle may exhibit anterior, horizontal, or lateral dis- 
placement, or may be completely rotated, the epididymis lying in front, 
the free border to the rear. The possibility of this displacement must 
be considered in tapping for hydrocele. 

Affections of the Testicle and Epididymis Characterized by Acute 
Inflammatory Phenomena. — Torsion of the testicle may be either to the 
right or to the left, and, in accordance with its extent and the degree of 
constriction to which the vessels are subject, the symptoms are slight or 
severe. In slight cases the epididymis alone becomes infiltrated. In 
severe cases the entire gland with the epididymis becomes gangrenous. 

The symptoms of torsion are those of orchi-epididymitis of a hyper- 



THE TESTICLE AND EPIDIDYMIS 653 

acute type appearing suddenly and causelessly during active muscular 
exertion. Attacking an undescended testis, the symptoms are akin to 
those of internal strangulation. In any case the diagnosis can be made 
only by incision. 

Contusion of the Testicle. — Acute traumatic orchi-epididymitis is char- 
acterized by sickening pain so severe as to cause syncope, sometimes 
death. The testicle is retracted and there is rapid swelling. The 
pain, at first overwhelming, is followed by a constant ache aggravated 
by standing, coughing, or straining, and so wearing as to enjoin anodynes 
and rest in bed; subsiding in three to five days, and leaving a testis 
prone to atrophy. 

Acute epididymoorchitis from strain properly belongs to contusion, 
since the injury inflicted on the testicle is incident to the sudden jerk 
on the part of the cremaster muscle, or to blood effusion incident to the 
venous congestion of abdominal strain. 

A descending infection often follows hard upon a strain. The onset 
is not sudden, and such cases usually assume the type of the ordinary 
epididymitis and are not followed by atrophy. 

When, after a comparatively slight trauma, testicular lesions persist 
and progress, it may be suspected that there was a latent tuberculosis, 
syphilis, or malignant infiltration before the injury. 

Luxation of the testicle may be due to trauma or muscular action. 
The usual cause is sudden, violent contraction of the cremaster muscle, 
which may fix the testis in the groin external to the ring from tonic 
spasm, may lodge it in the inguinal canal, or may draw it within the 
abdominal cavity. The testis is usually found within the inguinal 
canal acutely inflamed, because of the violence to which it has been 
subjected, and exhibiting tenderness and tumor sufficiently characteristic. 

Urethral epididymitis is an expression of inflammation carried along 
the vas. It is a common sequel of gonorrheal and of instrumental 
urethritis; it occasionally complicates gouty urethritis. 

The diagnostic symptoms are a tender edematous swelling at the back 
of the testis as large as this gland or even larger; tenderness and swelling 
along the cord; severe pain in the testis and back aggravated by standing, 
walking, or straining; shortly an effusion into the tunica vaginalis con- 
stituting an acute hydrocele, and simulating a swollen testicle; often 
tender, swollen ampulla and seminal vesicle detected on rectal exami- 
nation; fever and mental depression. The urethral origin of the infec- 
tion is established by the presence of a purulent discharge from the 
meatus, or of pus of posturethral origin in the urine (see p. 675). 

Tympany and vomiting, and tenderness, pain, and rigidity in the 
right iliac fossa may be prodromal symptoms due to peritoneal extension 
from the inflamed seminal vesicle. The symptoms reach their height 
in about five days. 

In some cases the onset is insidious, the progress non-crippling, 
provided proper support be worn, and the sole symptom, aside from 
urethral pus, an enlarged epididymis, w^hich may almost completely 
surround the testis. 



654 THE GENITO-URINARY ORGANS 

Gonorrheal epididymitis rarely suppurates, and, as a rule, undergoes 
almost complete resolution, leaving a permanent induration in the tail 
of the epididymis,' which, exceptionally, completely and permanently 
blocks the channel against the passage of spermatozoa. 

Urethral epididymitis of catheter origin (mixed infection) often gives 
rise to destructive abscess formation, characterized by softening, the 
discharge of pus, and at times the formation of multiple sinuses burrowing 
through enormously thickened scrotal tissues. Such abscesses may 
terminate in complete sloughing of both the epididymis and the testis. 

As a result of abscess, fungus may develop characterized by exuberant 
granulations usually from the scrotal tissue. If from the testicle or 
epididymis, the discharge will contain the glandular or tubular structure 
of these organs. 

Tuberculous epididymitis exceptionally begins precisely as does an 
acute gonorrheal epididymitis; the diagnosis must at first be based 
upon the absence of gonococci or catheter infection as causative agents, 
and the usual association of tuberculous lesions elsewhere, particularly 
in the genito-urinary tract. The subsequent course of the affection 
will later suggest the diagnosis. 

Acute orchi-epididymitis may occur in the course of mumps, malaria, 
tonsillitis, typhoid, scarlatina, influenza, and gout. The symptoms 
are those of urethral epididymitis, except that there is no urethral 
infection, but slight hydrocele, and the testicle is the structure most 
seriously affected; hence it forms the bulk of the swelling, maintaining, 
however, its characteristic form. 

This inflammation is sometimes the sole expression of mumps. 
Diagnosis will then be based upon the absence of other causes of inflam- 
mation and the history of exposure to mumps. Mumps orchitis is 
often followed by atrophy. 

Typhoid and tonsillitis orchitis is like that secondary to mumps. 

Malarial orchitis is characterized by regular recurrence of attacks 
independent of other reason and the finding of the malarial organism. 

Gouty orchitis is recurrent and alternates with other gouty symptoms, 
disappearing when arthritis develops and reappearing as the latter sub- 
sides. It occurs in sudden seizures. 

Swellings of the Testicles and Epididymis without Symptoms of 
Acute Inflammation. — The fluid swellings are hydrocele, cysts of the 
epididymis or testis, and hematocele, the latter often giving the impres- 
sion of a solid tumor. 

The solid swellings are tuberculous, syphilitic, or malignant. Excep- 
tionally benign tumors develop. 

Hydrocele. — Hydrocele, the commonest scrotal tumor, is essentially 
an affection of infancy and old age. It is characterized in the adult 
by the development of a slowly growing (years), painless, smooth, tense, 
heavy, elastic, fluctuating, pyriform tumor, over which the skin is freely 
movable. The cord is not enlarged. Fluctuation is best elicited by 
holding the tumor flrmly in one hand and lightly percussing with a 
finger of the other. 



THE TESTICLE AND EPIDIDYMIS 



655 



Translucency is the most convincing single sign aside from aspira- 
tion. This test is best conducted in a dark room and by means of 
a small electric light placed sufficiently deep within a small metal cup 
to allow the opening of the latter to be pressed closely against the 
scrotal skin, thus shutting in all rays except those which pass through 
the scrotum. In the absence of an electric light, translucency may be 
elicited by a candle held close to the tumor, over which the scrotal 
skin has been tensely stretched. The surgeon inspects from the side 

Fig. 433 




Tense hydrocele. Showing projection into groin. Dull on percussion. Irreducible. No impulse. 
Fluctuation present. Translucent. 

opposite the candle, shielding his eyes from the direct rays of the light 
by the open hand placed with its ulnar border on the convexity of the 
tense tumor. This inspection can be made through a tube — a cylin- 
drical proctoscope answers well — or a thick paper rolled into a cylinder 
and so held to the examining eye that light is excluded except that 
which passes through the hydrocele. 

To be diagnostic, the- translucency should be clear and unmistakable, 
since lipoma may give this symptom faintly. 



656 THE GENITO-URINARY ORGANS 

The final diagnosis is made by the aspiration of a fluid which may be 
clear, or turbid from admixture with cholesterin, blood, or spermatozoa 
(encysted hydrocele). 

The position of the testicle in regard to the fluid can usually be deter- 
mined by digital pressure, the latter eliciting the typical tenderness. 
Moreover, where the testicle lies there will be diminished translucency. 
When fluctuation, translucency, and testicular sensation cannot be 
elicited, diagnosis should be made by incision. 

Hydrocele of the tunica vaginalis may be bilocular or multilocular, 
and may occur in the acute form, in which case it is usually secondary 
to epididymitis. 

Chronic hydrocele usually distends the closed sac of the tunica 
vaginalis alone; it may also involve its funicular process (infantile 
hydrocele), or if a communication between that and the peritoneum 
still exists, it may communicate with the general abdominal cavity 
(congenital hydrocele). If the testis be in the inguinal region, the 
hydrocele will, of course, develop here. 

A huge hydrocele extending up into the inguinal canal may be diffi- 
cult to distinguish from irreducible omental hernia, or the latter may 
be a complicating factor. The history of the case, when this can be 
elicited, is conclusive, hernia beginning from above and the hydro- 
cele from below. Moreover, hernia is usually, in its early develop- 
ment, an intermittent tumor dependent upon abdominal strain for its 
recurrence. 

The distinction between hydrocele and hernia of the undescended 
testis will be based upon the distinct fluctuation of hydrocele, its persist- 
ence, and the absence of the usual attributes of hernia. At times the 
differential diagnosis is not possible. This is particularly the case in 
the congenital form of hydrocele. The inguinal hydrocele is often 
bilocular. 

Cysts of the Epididymis and Testicle. — These cysts usually grow 
from the head of the epididymis, forming an elastic, rounded, or multi- 
locular tumor just above the testicle, of varying size but rarely larger 
than the gland itself, giving rise to no symptoms, and stationary or 
exceedingly slow in growth. Such cysts usually contain spermatozoa, 
hence the translucence is not as marked as in the case of hydrocele. 
Diagnosis is based upon the absolute indolence of the affection and, 
if tuberculosis be suspected, exploratory incision. Because of the 
tension of the fluid in these cysts they are often mistaken for solid 
tumors. 

Encysted hydrocele of the testicle arises from the substance of the 
latter and forms a tense, circumscribed, elastic tumor covered by the 
visceral layer of the tunica vaginalis. It usually contains a fluid turbid 
with spermatozoa. 

Loose bodies in the tunica vaginalis are usually discovered accident- 
ally. They present a smooth surface, move freely, and are accompanied 
by a slight degree of hydrocele. The trouble caused by these bodies 
is usually psychic rather than physical. 



THE TESTICLE AND EPIDIDYMIS 657 

Hematocele. — Hematocele may be acute or chronic in its develop- 
ment. In the former case, incident to trauma or violent muscular 
strain, it forms a fluctuating tumor, non-translucent, entirely enveloping 
the testis, and corresponding to its shape. There is usually an accom- 
panying ecchymosis of the scrotum. 

There may be complete resolution, or the condition may degenerate 
into a chronic one. 

Chronic hematocele is characterized by a thickening of the vaginal 
tunic, often of such degree as to simulate a solid tumor. The testicle 
proper commonly lies in the posterior wall of this thickened mass, and 
ultimately undergoes pressure atrophy. It is an affection of early old 
age, exhibits a smooth, rounded, unbossed tumor, beginning with a strain, 
trauma, or preexisting hydrocele, growing slowly (years), and with 
periods of acute exacerbation, attended with moderate inflammatory 
symptoms, due to fresh hemorrhages into the sac. 

The diagnosis, unless the time limit (years) excludes malignant growth, 
should be made by incision, since aspiration is not sufficiently conclusive. 

Intratesticular hematocele would be suggested by severe, crippling, 
persistent (weeks) testicular pain following trauma. 

Tuberculosis. — Tuberculosis attacks the epididymis by preference, 
usually its head, forming one or more nodules which soften and dis- 
charge (months or years). Exceptionally the outbreak is acute, simu- 
lating the gonorrheal form of epididymitis, followed by persistence of 
infiltrations and nodulations, involving not merely the tail of the epididy- 
mis, but the whole of its substance. 

The usual form is characterized by the painless development of one 
or more nodules, usually discovered accidentally. Sometimes accom- 
panied by a slight sense of weight and dragging, which leads the patient 
to make an examination. There is very commonly a preceding and 
associated slight mucopurulent urethral discharge, together with evi- 
dences of tuberculosis elsewhere, particularly in the genito-urinary 
tract. 

The characteristic features of the affection are the inadequacy of a 
cause other than tuberculosis to produce usually in young adults an 
indolent, painless, nodular, often bilateral swelling of the epididymis, 
which ultimately tends to an almost painless breaking down, leaving 
one or more sinuses which discharge cheesy pus. Exceptionally, the 
tuberculous foci become permanently encysted. The cord is usually 
thickened and finely nodular. 

The tuberculin test, microscopic examination of the wound discharge, 
injection of accompanying hydrocele fluid into guinea-pigs, are all means 
of diagnostic corroboration. 

The affection is usually bilateral, nor will prompt removal of the 
affected testis prevent a secondary involvement of the remaining appar- 
ently healthy one. 

In infants, tuberculosis affects by preference, the body of the testis; 
it may have a subacute onset, appearing first as a hydrocele or as a tender, 
swollen testis, with reddening of the overlying scrotum. Persistence of 
42 



658 THE GENITO-URINARY ORGANS 

inflammatory symptoms and early softening and sinus formation are 
characteristic features. If syphilis be excluded as a cause of the 
nodular infiltration, distinction from neoplasm should be made by 
operation. 

Cysts of the epididymis are more elastic and sharply rounded than 
tuberculous infiltrates, the body and tail of the epididymis remain per- 
fectly normal to palpation, and there is no tendency to sinus formation. 

Gumma usually involves the testicle first, and is characterized by a 
history of syphilis, the presence or traces of other specific lesions, and 
absence of tuberculous stigmata. 

Syphilis of the Testicle. — Syphilis of the testicle is usually expressed 
in the form of sometimes symmetrical, usually bosselated or ridged, 
painless, densely hard, often bilateral enlargement, associated with a 
moderate degree of hydrocele; persisting for months with slow increment. 
The cord is not enlarged. On reaching the size of a fist, the infiltrate 
undergoes resolution, leaving an atrophied and distorted testis, or 
breaks down, discharging gummy pus. Exceptionally the onset is 
characterized by the symptoms of a mild or acute orchitis. 

The diagnosis is based upon the history and associated symptoms of 
syphilis, the absence of inflammatory phenomena, the at first rapid 
(weeks) then slow (months) progress, and the therapeutic test. When 
the onset is subacute, the diagnosis must be by exclusion, and must 
depend upon the history of the case and the therapeutic test. 

From tuberculosis the distinction may be made, in the adult, by the 
fact that the latter nearly always attacks the epididymis first and exhibits 
lesions elsewhere. 

From malignant infiltration, a timely diagnosis must depend upon the 
history of the case, a therapeutic test, and incision and microscopic 
examination. 

Malignant Tumor of the Testicle. — Malignant tumor of the testicle, 
usually in the form of soft carcinoma, at times mixed sarcoma, and 
commonly enough beginning with trauma or inflammation, usually 
develops before middle age; occasionally in children. It is char- 
acterized by a comparatively painless, usually symmetrical, rapid 
(weeks or months) enlargement of the testis. The postperitoneal 
glands are quickly invaded. 

The diagnosis based upon the presence of a rapidly increasing 
enlargement in the absence of adequate cause other than malignancy 
should be made by incision and microscopic examination, since, when 
the features of the case are such as to be entirely characteristic, i. e., 
large tumor, dilated veins, and involved lymphatics, operative treatment 
is futile. 

Neuralgia of the Testicle. — Neuralgia of the testicle, by which is meant 
intense, persistently recurring pain, without demonstrable lesion, is 
sufficiently often dependent upon either varicocele, encysted hematocele, 
or a beginning tuberculous or malignant infiltration to justify exploratory 
operation. 



THE SPERMATIC CORD 659 



THE SPERMATIC CORD. 

The vas may be absent on one or both sides without other obvious 
defect. 

Trauma or muscular strain may cause hemorrhage characterized 
by the rapid formation of a doughy, sausage-shaped tumor, occupying 
the position of the cord, simulating hernia of sudden formation. 

Acute funiculitis is a common accompaniment of urethral epididy- 
mitis and is characterized by pain, tenderness, and thickening. 

In the course of tuberculous epididymitis the vas is very commonly 
finely nodular and infiltrated, and the whole cord is thickened. 

In malignant infiltration the cord is often enormously thickened. 

Varicocele is the commonest affection of the cord. It is characterized 
by a soft mass of thickened, dilated, and tortuous veins occupying 
the position of the cord, not only palpable, but often obvious to inspec- 
tion. In its extreme development it gives impulse on coughing, and 
partially disappears on taking the recumbent posture. Exceptionally 
it is attended with atrophy of the testis. It occasions psychic rather 
than physical disturbance, but occasionally neuralgic pain and sexual 
neurasthenia are distinctly referable to it. 

It is an affection of youth, appearing after maturity without obvious 
cause. It is suggestive of venous obstruction of postperitoneal origin, 
particularly of hypernephroma. 

The distinction from omental hernia is made from the peculiar worm- 
like feeling characteristic of the dilated, tortuous, and often thickened 
veins, the fact that the tumor began in the lower part of the scrotum, 
that it can be partly reduced by the recumbent posture, and pressure 
over the internal or the external ring on resumption of the erect position 
does not prevent its slowly growing large from below upward. 

From discrete lipoma, diagnosis will be made w^ith difficulty. There 
is no alteration in the size of lipoma dependent upon position or intra- 
abdominal strain. Moreover, this affection is extremely rare. 

Hydrocele of the cord, usually seen in infants, forms a soft, fluctuating, 
translucent tumor occupying the position of the cord; beneath it the 
testicle can be felt. It may be acute in development, in wdiich case it 
is rather an edema than an effusion into a patulous funicular portion 
of the vaginal tunic. 

The encysted hydrocele of the cord is (patulous, funicular portion of 
the vaginal tunic) insidious in development, chronic in course, unilocular 
or multilocular, common in children, but noted in the adult, and often 
complicated by hernia. It appears as a smooth, tense, ovoid swelling 
in some portion of the spermatic cord. Beneath this the testis can 
usually be recognized. It is usually mistaken for hernia, and can often 
be pressed back into the inguinal canal, but cannot be really reduced. 
Moreover, translucency is present, nor are the characteristic features 
of hernia to be found unless this condition be associated with congenital 
hydrocele. 



660 THE GENITO-URINARY ORGANS 

Lipoma of the cord (rare) forms a slow (years), soft, painless, ill-defined 
growth in the course of the cord, between the structures of which it may 
intimately infiltrate. The tumor grows from below upward. When 
it has traversed the inguinal canal, the distinction between it and irre- 
ducible omental hernia can be made only on the history of the case 
and examination through an incision. 



THE SEMINAL VESICLES. 

The seminal vesicles form two lobulated pouches inclosed in dense 
fascia, passing from the walls of the bladder to the posterior border of 
the prostate. They vary greatly in size within normal limits, averaging 
about two and one-half inches in length and one-half inch in breadth, 
and terminating in a duct which unites with the vas just before the latter 
enters the substance of the prostate. The upper extremities of the 
seminal vesicles are in close relation to the peritoneum of the rectovesical 
pouch. The function of the vesicles is entirely secretory. 

Malformations. — One or both seminal vesicles may be absent, usually 
associated with other malformations of the sexual organs. They may 
be fused, multiple, or atrophic. Or they may communicate with the 
ureter. 

The ejaculatory duct, formed by the fusion of the vas and duct of the 
seminal vesicle, normally pierces the prostatic isthmus, opening at the sides 
of the prostatic utricle. This duct may be absent, partially wanting, or 
fused, or it may be continued forward, forming a canal which opens at 
some point on the glans penis, suggesting a double urethra. 

Acute Vesiculitis. — ^Acute vesiculitis, or spermatocystitis, is due to 
extension of infiammation, usually gonococcal, from the posterior urethra 
into the seminal vesicle. The symptoms are those of aggravated posterior 
urethritis (see p. 667), except that the pain radiations are character- 
istic, being referred not only to the perineum, anus, and hypogastric 
region, but also to the hip-joint of the affected side and the outer surface 
of the leg. Frequent erection and painful nocturnal emissions of blood- 
stained purulent semen are common. 

Exceptionally seminal vesiculitis is ushered in with the vomiting, 
tympany, and symptoms of acute local peritonitis, even including 
rigidity and tenderness on deep pressure in the iliac fossa corresponding 
to the seminal vesicle involved. If this be the right one, a diagnostic 
error may readily be made. 

The diagnosis is based upon rectal examination. If practicable the 
patient should have a fairly full bladder and should lean forward sup- 
porting himself by the hands placed upon a table or chair, with the legs 
slightly separated. Lying above the prostate and extending obliquely 
upward and outward from it will be found a tender mass, usually about 
the size of the thumb. When both vesicles are infiamed there is felt 
above the prostate a hot, broad, tender infiltration suggesting on palpa- 
tion an enormously enlarged prostate. This is lacking in the density 



THE SEMINAL VESICLES 661 

of true prostatic swelling and on careful palpation the prostate can be 
distinctly outlined below the mass. 

A distinction between seminal vesiculitis and inflammation of the 
ampulla of the vas cannot be made. 

Chronic Vesiculitis.— Chronic vesiculitis is the usual termination of an 
acute attack. It may, however, develop with symptoms so slight as to 
attract little attention. It is practically always complicated by posterior 
urethritis and is a common cause for the continuance of this condition. 

It is characterized by sexual neurasthenia, slight anemia of the toxic 
type, usually a persistent gleet, and recurring attacks of subacute or 
acute urethritis from inadequate cause. Monoarticular or polyarticular 
rheumatism is a not infrequent expression of systemic infection, even in 
the absence of marked local symptoms. Pus in the urine is constant; 
anterior discharge appears during the subacute or acute attacks. 

These symptoms do not differ from those of a chronic posterior ure- 
thritis kept up by persistent infection of glands or follicles, hence the 
diagnosis can be made only by rectal examination, which demonstrates 
a swollen, usually softly bossed, sometimes nodular vesicle, from which 
can be expressed pus and blood. For the collection of this the patient 
passes a small part of his urine. The prostate is then massaged, and 
he urinates again, but does not empty the bladder. The vesicles are 
next massaged and the urine remaining in the bladder is passed. In 
this last portion will be found the pus expressed from the vasal ampullae 
and the seminal vesicles. 

Tuberculous Vesiculitis. — ^Tuberculous vesiculitis is usually associated 
with other tuberculous lesions, particularly with nephritis, cystitis, and 
epididymitis. 

If the bladder be free from invasion, the symptoms are slight or wanting. 
When present, they are those of chronic posterior urethritis. Sexual 
erythism, bloody semen, and pain during and after ejaculation are 
frequently noted. 

The diagnosis is based upon the finding by rectal examination of an 
irregular, nodular, non-sensitive growth occupying the position of the 
seminal vesicle; not explainable from a history of a preceding gono- 
coccal or infectious urethritis, slowly and obstinately progressive, made 
worse by ordinary treatment applicable to chronic seminal vesiculitis, 
and associated with the evidences of tuberculous invasion elsewhere. 

Absolute diagnosis is made by finding tubercle bacilli in the urine or in 
the expressed discharge. 

Cysts of the seminal vesicles, due to obstruction of the ejaculatory 
ducts, are characterized by pressure symptoms. Diagnosis is based upon 
rectal palpation and the position of the cysts. These can be differen- 
tiated from dermoid cysts similarly placed only by operation. Concre- 
tions sometimes form in the seminal vesicle and become of surgical 
interest only when they produce blocking of the ejaculatory duct. 

Painful emissions and the symptoms of chronic vesiculitis suggest a 
rectal examination which shows the presence of one or more bodies of 
stone-like hardness lying between the bladder wall and the rectum. 



662 THE GENITO-URINARY ORGANS 

Malignant infiltration of the seminal vesicle is always secondary to that 
of the prostate. It is characterized by a stony induration confluent with 
an equally dense prostate. 

THE PROSTATE. 

The average normal adult prostate is about one and one-half inches 
wide, one and one-quarter inches long, and three-quarters of an inch 
thick, weighing about five drams; it is made up of glandular tissue and 
smooth muscular fibers. In shape it resembles somewhat a chestnut, 
but is subject to marked variations in both shape and size. On rectal 
examination it is distinctly bilobed, the two halves being connected by 
an isthmus which sometimes forms a distinct projection called the third 
lobe. This isthmus lies just below the vesical orifice of the urethra 
and above and behind the ejaculatory ducts, discharging its secretion 
into that portion of the urethra which lies nearest the bladder. 

The prostate is situated behind and slightly below the symphysis 
pubis, lying between the posterior layer of the triangular ligament and 
the neck of the bladder, which is surrounded by its base. It is 
separated from the rectum by a thin, rectovesical fascia and by the 
prostatic sheath. The latter completely invests the gland, forming a 
tough, connective-tissue covering in which are found the large veins 
of the prostatic plexus. 

The symptoms common to surgical affections of the prostate are en- 
largement or deformity, detected by rectal, urethral, or cystoscopic 
examination, interference with the function of micturition, and pain. 

Inflammatory Affections of the Prostate. — Acute Prostatitis is usually 
due to extension of gonorrheal or catheter urethritis. The symptoms 
are pus in the urine from the originating urethral infection, a feeling 
of weight in the perineum, pain greatly increased by urination and defe- 
cation, frequency in urination, possible difficulty in starting the stream, 
failure to experience complete relief after the bladder is apparently 
emptied, and either circumscribed or diffuse prostatic tenderness and 
swelling detected by rectal examination. 

If inflammation goes on to abscess formation there are the local and 
constitutional signs of this affection, i. g., increase of pain which becomes 
throbbing, burning, and almost unendurable in its intensity, added 
difficulty in urination, and constitutional symptoms of deep pus. Fluc- 
tuation may be detected by rectal palpation. 

Complete retention is common, and because of associated pelvic 
congestion, hemorrhoids are a frequent complication. 

The symptoms are so like those of a posterior urethritis that diagnosis 
must be based upon rectal palpation which reveals a hot, tender tumor 
occupying the position of the prostate. 

If the abscess be confined to one or more prostatic follicles, these 
commonly open into the urethra, giving prompt relief, with increase of 
the discharge, often with some blood admixture. This is the usual ter- 
mination. If the abscess has burst its glandular environment, involving 



THE PROSTATE 663 

a part or the whole of the substance of the prostate, rupture may still 
take place into the urethra or rectum, or the pus may burrow through 
the pelvis, forming multiple fistulse opening in regions remote from the 
prostate, and exceedingly difficult to heal. 

Exceptionally a huge pelvic abscess of prostatic origin may develop, 
with almost no symptoms, the diagnosis being formulated on symptoms 
of profound sepsis and the findings by rectal examination. 

Chronic prostatitis is predisposed to by congestion, such as that incident 
to prolonged ungratified sexual excitement, excessive coitus, masturba- 
tion, habitual constipation, urethral stricture, or irritating conditions of 
the urine. It is directly caused by infection. 

It ■ is characterized by increased frequency of urination and often 
burning pain during and after the act, deep perineal pains radiating 
to the rectum and down the thighs, made worse by exertion, slight 
perineal tenderness, induration, possibly nodulation, of the prostate, pus 
in the urine at times. There are frequently intercurrent subacute attacks 
of inflammation, the general symptoms of mild septic absorption, such 
as headache, backache, myalgia, and indigestion, sexual neurasthenia, 
and a slight toxic anemia. On rectal examination the prostate may 
be unduly sensitive at some portion of its surface, this tenderness being 
nearly always localized. The urine passed after milking the prostate 
contains a considerable quantity of pus. 

Chronic prostatitis may persist for years with no symptoms other than 
pus in the urine, detected only by careful examination. 

Calculi of the Prostate. — Prostatic calculi, usually due to deposits of 
lime salts in suppurating prostatic follicles or abscess cavities, excep- 
tionally to concretions formed about the corpora amylacea, are found 
in the region of. the verumontanum. They may give no symptoms. 
Usually they are characterized by those of posterior urethritis. 

The diagnosis is made by rectal palpation and urethral examination. 
If the calculi are large, they can usually be felt by the finger introduced 
into the rectum. They may also be detected by the passage of metal 
instruments, which will give a click, or by the introduction of the 
urethroscope. The rr-rays give a characteristic shadow. 

The distinction from vesical calculi will be made by the fixed position 
of the stones, determined by passing a metal instrument with the finger 
in the rectum. 

Enlargement of the Prostate. — ^This is an affection of middle and old 
age. It is characterized solely by obstructive symptoms, to which, when 
infection occurs, are added those of infiammation. 

The typical obstructive symptoms are increased frequency of micturi- 
tion most marked during the night or early in the morning, delay in 
starting the stream, loss of force, interruptions during the passage of the 
stream, and dribbling at the completion of the act. Later, when the 
bladder becomes distended, there may be incontinence due to the over- 
fiow of urine from an atonic and greatly dilated bladder. 

There is usually polyuria due to back pressure and slight albuminuria, 
with hyaline casts. 



664 THE GENITO-URINARY ORGANS 

When inflammation is added to obstruction, urgency, pain, and pyuria 
further compHcate the picture. 

The diagnosis is based upon rectal palpation, measurement of urethral 
length, cystoscopic or instrumental examination of the posterior urethra 
and its vesical orifice, and the detection of residual urine. 

Hypersecretion of urine may occasion frequency, but without the other 
symptoms of enlarged prostate. 

Sclerosis and contracture of the internal vesical sphincter will produce 
all the symptoms of prostatic hypertrophy, with the exception of enlarge- 
ment felt through the rectum and increased urethral length. 

Stricture will produce all the symptoms, but the history of a pre- 
ceding trauma or inflammation (usually years before) and the passage 
of a urethral instrument will clear the diagnosis. Moreover, the pros- 
tate is not found unduly enlarged on rectal examination. 

To determine the extent to which the urethra is lengthened, a soft 
elbowed catheter is employed. This is first passed down to the membran- 
ous urethra. The anterior urethra is then thoroughly flushed out with 
a mild antiseptic solution. The catheter is pushed on until the urine 
begins to flow. A point on the shaft corresponding to the meatus is 
marked and after the bladder has been emptied the catheter is withdrawn 
and the distance from this mark to the eye of the instrument is taken. 
This measurement represents roughly the urethral length. If it be 
more than eight to eight and one-half inches, this suggests prostatic 
enlargement. 

The thickness of the isthmus, the so-called median lobe, can be 
determined by introducing a sound into the bladder and palpating 
on this through the rectum. Moreover, by means of this sound, if it 
be provided with a sharp curve such as is common in stone sounds, 
the size, and the direction of intravesical projections can be roughly 
determined. This can be more accurately done by the use of the cysto- 
scopy 

The amount of residual urine is estimated by directing the patient 
to empty the bladder, then introducing the soft catheter and drawing 
off all that remains. Normally not more than a few drops of urine 
should be drawn. 

Unusually severe pain and tenesmus, especially if associated with 
blood and pus in the urine, should suggest vesical stone as a complica- 
tion of the enlarged prostate. 

Contracture or sclerosis of the internal vesical sphincter is characterized 
by the symptoms of prostatic obstruction. The retention is even more 
complete and the suffering incident to catheter infection more marked. 
The diagnosis can be made only by rectal examination, which shows often 
a small, hard prostate, and by the passage of instruments which demon- 
strate a short posterior urethra, no intravesical prostatic projections, no 
lateral deviation of the sound, and obstruction to the introduction of 
the instrument only at the vesical neck. 

Malignant tumor of the prostate is characterized by precisely the symp- 
toms of prostatic enlargement, differing from these only in the fact that 



THE URETHRA 665 

the tumor is of stony hardness. As a rule, the growth is small, progresses 
slowly, and begins in the posterior portion of the lateral lobes. Metas- 
tases to the bones, particularly those of the lumbar vertebrse, may occur 
before the local symptoms are sufficiently severe to lead to examination. 
The growth exhibits a tendency to extend upward along the course of 
the seminal vesicles, which are promptly invaded. 

The diagnosis can be made at a time when this is serviceable to the 
patient only by excision. In its late development hemorrhage, pain, 
and extensive induration, with involvement of the rectum and bladder, 
make the diagnosis unmistakable. 



THE URETHRA. 

The urethra, a mucous canal, abundantly supplied with glands and 
follicles, is about eight inches long in the adult. It is narrowest at the 
meatus and in its membranous portion. Just behind the meatus and 
in its prostatic and bulbous portions are areas of physiological dilata- 
tion. It should normally take a 32 sound, except for the natural meatal 
narrowing, which may be so small that a 22 cannot be passed without 
traumatism. 

A congenital narrowing, persisting until puberty below this gauge, 
usually gives rise to some bladder irritability and favors the development 
of urethral discharge. 

Normally there should be no discharge from the urethra except a slight 
transparent mucus following prolonged erection, nor should there be 
dribbling of urine following micturition beyond two or three drops, 
readily shaken off. 

The anterior urethra, six inches in length, is surrounded by the 
erectile tissue of the spongy body. 

The posterior urethra in its first three-quarters of an inch lies between 
the anterior and posterior layers of the triangular ligament, surrounded 
by the compressor urethrse muscle. The prostatic portion of the pos- 
terior urethra, one and one-quarter inches long, runs through the upper 
portion of the prostate gland. 

Inflammation of the anterior urethra is characterized by discharge from 
the meatus, pain aggravated by the act of urination and by erection 
which may be painful. 

Obstruction to the free passage of the urine is characterized by slight 
urethral discharge, alteration in the force and volume of the stream 
passed, dribbling at the end of urination, and undue frequency of the act. 

Inflammation of the posterior urethra is characterized by pus found 
both in the first and the second portions of urine if this be passed from 
a full bladder in two parts. This, together with backache in the sacral 
region and sexual neurasthenia, may be the only symptom if the affec- 
tion be chronic. 

In acute cases there is pain, usually referred to the meatus or just behind 
it and felt in the perineum, anus, and down the inner surfaces of the 



666 THE GENITO-URINARY ORGANS 

thighs, severe aching in the same region, frequent urgent painful urina- 
tion, with, in hyperacute cases, a few drops of blood at the end of the 
act. Frequently there are recurring erections and painful emissions. 

Malformations of the Urethra. — ^The urethra may be absent, ob- 
literated, congenitally strictured, sacculated, or deficient as to its floor 
or its roof. 

Atresia or obstruction of an otherwise well-formed urethra, is likely 
to be observed near the meatus. 

Hypospadia. — Hypospadia, or deficiency of the floor to the urethra, 
is comparatively common. The urethra may terminate at the base of 
the glans (balanic), between the glans and the penoscrotal junction 
(penile), or in the scrotal cleft or perineum (perineal). The balanic 
form is the usual one. It is commonly associated with a normally 
placed meatus which opens into a blind pouch. 

Epispadia. — Epispadia, or deficiency of the urethral roof, is a rare 
deformity, likely to be complicated by exstrophy of the bladder or other 
malformations. Though it may appear simply in the balanic form, 
the abnormal opening will usually be found just in front of the pubic 
symphysis, or the position this should occupy, since it may be congeni- 
tally absent. 

Narrowings of the urethra, whether congenital or acquired, are char- 
acterized by frequent, difficult urination. 

Congenital pouches, due to a deficiency of the spongy body, are marked 
by obvious distention at the time of urination and subsequent dribbling 
as the pouch is gradually emptied. 

Traumatic subcutaneous rupture of the urethra is characterized by 
pain, urethral hemorrhage, the immediate formation of a circumscribed 
tumor at the seat of injury, and difiiculty in passing urine, or complete 
retention. 

When this rupture has been accomplished by rough instrumentation, 
immediate free bleeding and severe pain followed by a mucopurulent 
discharge may be the only symptoms immediate or remote. Exception- 
ally it is followed by extravasations of urine. 

When the rupture is due to force from without, the external swelling 
increases and becomes diffuse and is shortly (days) followed by brawny, 
widespread edema, due to urinary extravasation. This edema in the 
case of the anterior urethra is confined to the scrotum, the penis, and 
later the anterior belly wall. 

If the fibrous envelope of the spongy body has not been torn through, 
the extravasation may not involve the tissues of the scrotum, but may 
travel forward, producing cellulitis and gangrene of the spongy body and 
the glans. More commonly it forms a circumscribed abscess. 

When the rupture involves the posterior urethra (membranous and 
prostatic part) there is neither bleeding from the meatus nor any external 
sign of blood tumor. There is pain and complete retention or the strain- 
ing passage of bloody urine. The urinary extravasation may pass for- 
ward taking the course of that incident to rupture of the anterior urethra, 
or may infiltrate the pelvis, giving no signs other than the constitutional 



THE URETHRA 667 

ones of an extensive cellulitis and perhaps a boggy swelling detected by 
rectal examination. 

The posterior urethra is particularly likely to be torn by falling 
astride of a narrow surface, such as the edge of a plank, or by forces 
which disrupt the pelvis. The bleeding then takes place into the 
surrounding cellular tissue and the blood flows back into the 
bladder. 

The absolute diagnosis of urethral rupture is made by instrumental 
examination. A soft instrument will be arrested at the seat of tear if 
this be complete. If it be partial, there will be a sense of obstruction 
which, on yielding, allows the instrument to pass into the bladder. From 
this clear urine will be drawn in the case of tears of the anterior urethra; 
bloody urine, if the posterior urethra be torn. A further diagnosis may . 
be made by direct inspection through a cystoscopic tube. 

Diagnosis of extravasation will be based upon the rapid extension of 
brawny edema in the case of rupture of the anterior urethra, possibly 
by the detection of pelvic edema on rectal examination if the posterior 
urethra be involved, associated in either case with the constitutional 
symptoms of septic cellulitis. 

Foreign bodies in the urethra give rise to pain and obstruction to urin- 
ation. If the body be lodged in the anterior urethra for more than 
twenty-four hours, there will be a blood-stained, mucopurulent discharge. 
If of sufficient size, it can usually be detected by external palpation. If 
the foreign body be a calculus, there will be a sudden arrest of urine, often 
accompanied by sharp pain, frequently preceded by a history of renal 
colic. The sound and the urethroscope will not only prove the presence 
of the foreign body, but usually show its nature. 

Inflammatory Affection of the Urethra. — Urethritis. — The only 
constant symptom of urethritis is pus either escaping from the meatus 
or found in the urine. Inflammation of the anterior urethra always 
causes a urethral discharge unless the secretion of pus be so slight that 
it is washed away by each act of micturition before a sufficient quantity 
accumulates to become obvious at the meatus. 

Discharge from the posterior urethra usually flows back into the 
bladder, hence may be profuse without appearing at the meatus. 

In determining from what part of the urethra the pus comes the patient 
is directed to hold his urine for from four to eight hours; this is con- 
veniently done during the night, the test being made at the time of his 
first urination on waking up. He is directed to pass his urine into two 
glasses, the first part in one, the last part in another. If he is suffering 
from a free urethral discharge involving both the anterior and posterior 
urethra, both portions of urine will show the presence of pus, but usually 
there wiU be much less in the last portion. If the posterior urethra is 
free from inflammation, the second portion of urine passed will fail to 
show pus. 

Symptoms of urethritis other than pus are present or absent in 
accordance with the severity of the inflammation, and bear no neces- 
sary relation to the particular form of infection 



668 THE GENITO-URINARY ORGANS 

Aside from urorrhea, characterized by a moderate mucous discharge 
containing few leukocytes, much epithehum and the bacteria customarily 
found in the normal healthy urethra, and developing in the relaxed and 
cachectic, all discharges indicate the presence of inflammation. 

Acute traumatic urethritis, i. e., incident to instrumentation, irritating 
injections (common), exceptionally to external traumatism, is character- 
ized by a blood-stained, purulent discharge which usually disappears in 
three to seven days. The discharge following strong bichloride injections 
may, however, be quite as persistent as that due to gonococcal infection. 
The diagnosis is made from the history of the case and by excluding the 
gonococcus (microscopic examination). 

Acute urethritis due to irritating conditions of the urine (rare). A 
mucopurulent discharge, with slight inflammatory symptoms, is some- 
times due to the ingestion of drugs or certain articles of food, such 
as turpentine, cubebs, copaiba, cantharides, alcohol, arsenic, iodides, 
asparagus, rhubarb, strawberries, and fish. Or the irritating quality of 
the urine may be due to high fever, to rheumatism, oxaluria, or phos- 
phaturia. The gonococcus must always be excluded before the diag- 
nosis of this form of urethritis can be formulated. 

Eruptive Urethritis (rare). — During the course of the acute exanthemata 
a slight urethral discharge is at times observed. Exceptionally this is an 
expression of urethral herpes, in which case it is likely to be accompanied 
by severe pain and the presence of herpetic lesions elsewhere. 

Simple infectious urethritis, at times called abortive gonorrhea, follows 
much the early course of gonorrhea, and is usually due to a similar 
form of exposure. It runs a short course, unattended with complications. 
Exceptionally it is as prolonged and complicated as the most obstinate 
infection. Gonococci are not found. 

Gonococcic Urethritis. — This, the commonest form of urethral inflamma- 
tion, is characterized by an acute urethral inflammation which comes on 
in from one to twelve, usually three, days after exposure. It becomes 
total within the first week. The diagnosis depends upon finding the 
gonococcus. 

Urethral and periurethral abscess, common complications of both gono- 
coccal and instrumental urethritis, are characterized by nodulation or 
induration along the urethral course and chordee, followed by softening 
and discharge either internally, externally, or in both directions, excep- 
tionally leading to urinary fistula or extravasation, and always followed 
by stricture. 

Cowperitis. — Suppuration of Cowper's gland, situated as it is between 
the two layers of the triangular ligament below the urethra, is attended by 
severe perineal pain, aggravated by defecation, and especially so by the 
terminal act of micturition, perineal tenderness so great as to make 
sitting or walking difficult, and the presence of a swelling behind the bulb, 
most readily detected by a finger passed just within the external sphincter 
and pressed upward and forward. The tumor is found to one side of the 
median line unless both glands are involved, and lies in front of the 
prostate — this is diagnostic. 



THE URETHRA 669 

The increased swelling incident to suppuration causes complete reten- 
tion of urine and marked aggravation of all symptoms. The abscess 
usually ruptures externally. Exceptionally into the urethra. It is not 
complicated by urinary extravasation. When the gland is not destroyed 
by abscess formation the inflammation may become chronic, indefinitely 
prolonging the urethritis. 

Pneumococcic and diphtheritic urethritis (rare) are overshadowed by 
the constitutional symptoms of the major disease. The diagnosis must 
be made by the finding of the specific organisms in the discharge. 

Syphilitic urethritis may be due to either primary, secondary, or 
tertiary syphilis. In its acute or subacute form it is always due to 
chancre, which is usually placed not deeper than half an inch from the 
meatus. There is moderate discharge, swelling about the frenum, 
and some obstruction to urination. Though there may be frequency 
because of obstruction, other posterior symptoms do not develop. In- 
guinal adenopathy or general eruption usually appears before the true 
nature of the affection is recognized. 

The long incubation (never less than two weeks), the chronic, non- 
progressive nature of the affection, and particularly bilateral, poly- 
glandular, painless enlargement of the inguinal glands should suggest an 
examination with the meatoscope or urethroscope, which would establish 
the diagnosis by showing the presence of a rounded, indolent ulcer. At 
times the mucopurulent discharge and obstructive swelling are not 
sufficient to excite attention, in which case secondary symptoms may 
occur without suspicion upon the part of the patient as to the true seat of 
infection. 

Chancroidal urethritis is always accompanied by an ulceration at or 
near the meatus, exliibiting the characteristics of a chancroid. 

The inflammation is limited to the region of the meatus, there are no 
symptoms of posterior urethritis, and no gonococci are found. 

Chronic Urethritis. — The causes of chronic urethritis are stricture, 
persistence of infection in glands and follicles, tuberculosis, syphilis, 
and urethral polypi. 

Stricture, even though it be of large caliber, is the commonest cause of 
chronic urethral discharge. It is best detected by square-shouldered 
metal bougies. An inflammation once started, a narrow meatus acts as 
a stricture. If the meatus be once passed, an unstrictured urethra should 
take a 32 F. bulbous bougie; this will be resisted by the accelerator urinse 
muscle and stopped by the compressor urethrse. On withdrawal it should 
not at any point give a distinct jump, such as comes when it is made to 
clear an obstruction. 

Next in order of frequency as a cause of chronic urethral discharge 
comes persistent infection of the glands and follicles. These act as foci 
for recurring subacute outbreaks. The diagnosis must be made by direct 
examination. After irrigation of the anterior urethra a bulbous bougie 
of full caliber is passed to the membranous urethra and withdrawn with 
a gentle swabbing motion; this milks the pus from the inflamed follicles, 
bringing it out on the shoulder of the bulb. 



670 THE GENITO-URINARY ORGANS 

From the posterior urethra after partial micturition massage of the 
prostate will usually bring an abundant supply of pus. A direct urethro- 
scopic examination may be essential for an absolute diagnosis. 

Tuberculous urethritis is characterized by apparently causeless, slight, 
persistent urethral discharge, which is not bettered by local treatment. 
Diagnosis is sometimes made by the finding of the tubercle bacillus, 
usually by the discovery of tuberculous lesions in other situations, 
particularly in the seminal vesicles or epididymis. With this discharge 
there is usually associated frequency of urination; later, tenesmus, pain 
and slight hematuria. 

Syphilitic urethritis as a manifestation of the urethral localization of 
the secondary eruption of syphilis (rare) is chronic, indolent, and 
practically without symptoms except for the discharge. The history, 
exclusion of other causes, and association with other more character- 
istic lesions of the infection will lead to a correct diagnosis. 

Urethral Polyps. — Urethral polyps (rare) are characterized by per- 
sistent moderate discharge; the diagnosis must be made by means of 
the urethroscope. 

THE BLADDER. 

The bladder, when healthy, has no absorbing power. It holds with 
comfort about twelve ounces; with slight distress, a pint. It is pro- 
vided with two sphincters. The internal vesical sphincter is in a 
condition of tonic contraction until the viscus contains from four to six 
ounces when it dilates, making the prostatic urethra a portion of the 
bladder cavity; the urine is then retained by the external sphincter, 
i. e., the compressor urethrse muscle. 

The vesical mucous membrane is made up of flat epithelium placed 
on a layer of cylindrical cells. It is of a yellowish color, and, because 
of the distensibility of the organ, exhibits many plications. The ureteral 
orifices of the bladder are protected against regurgitation by valves 
which become increasingly competent in proportion to intravesical 
tension. 

Most men empty the bladder on rising in the morning, after breakfast, 
during defecation, at noon, late in the afternoon, and on going to bed, 
passing from six to twelve ounces at each act of urination. 

Transitory undue frequency of urination in the absence of vesical or 
renal lesions follows the excessive ingestion of fluid, the use of diuretic 
drugs and articles of food, anxiety or any vivid emotion, or change from 
warm to cold weather. 

Persistent undue frequency of urination may be an expression of hyper- 
secretion, as in diabetes or chronic nephritis. Unassociated with 
hypersecretion, it may be due to irritating qualities of the urine, pro- 
ducing congestion and hence exaggerated reflexes. This symptom is 
common when the urine contains blood, phosphates, or oxalates, or is 
highly concentrated as the result of fever or indigestion. 

Incontinence of urine, unattended by vesical or renal lesions, is 



THE BLADDER 671 

characterized by the painless escape of urine with or without the 
consciousness of the individual. 

In its accidental form the affection is often called a weak bladder. 
The discharge is explosive, and comes from a sudden abdominal strain, 
which takes the sphincters off their guard, as in the act of laughing or 
coughing. In its transient form incontinence follows anesthesia, drunken- 
ness, sometimes prolonged involuntary retention. 

Persistent incontinence, independent of bladder lesion, is physiological 
in children up to the age of one or two years. In those of older growth 
the incontinence may be due to habit or degeneracy; if it be both diurnal 
and nocturnal, it is probably dependent upon an organic lesion. 

Nocturnal incontinence occurring in an adolescent or adult without 
local inflammatory or reflex cause is strongly suggestive of epilepsy or 
beginning ataxia. Visceral crises limited to the urinary organs occur in 
tabes. 

Attacks of profuse hematuria without other symptoms may be due 
to vesical varices, to aneurysm of the renal arteries, or to an essential 
renal hemorrhage. These conditions are all extremely rare. The usual 
cause is a bladder tumor, nor is the freedom of bleeding an index to the 
size of the tumor. 

Bacteriuria. — ^The urine may be swarming with bacteria without pus 
admixture. 

The organism usually causative of simple bacteriuria is the Bacillus 
coli communis. It gains entrance from the intestine in cases of chronic 
constipation, acute enteritis, dysentery, or typhoid fever. 

Typhoid bacteriuria exists in from 20 per cent, to 30 per cent, of cases 
of typhoid fever, usually in pure culture, appearing generally in the second 
to the third week of the disease, often associated with albuminuria, 
without pus, and rarely producing the morbid changes of cystitis, even 
though it persist for years. 

With the exception of hypersecretion of mucus and slight albuminuria, 
simple bacteriuria is unattended with inflammatory symptoms. Under 
local favoring conditions it may become converted into pyuric bacteriuria. 
Microscopic examination will at once determine the presence or absence 
of pus in quantity. 

The local symptoms when present are generally slight — frequency of 
micturition, mild ardor urinse, occasionally incontinence, and, in children, 
nervous disturbances. There may be a slight urethral discharge. So 
long as the epithelium of the urinary tract remains healthy there is no 
absorption of the bacterial toxins. If from imperfect drainage the 
bladder epithelium loses its vitality, absorption occurs and mild fever, 
lassitude, and digestive and nervous disturbances appear. 

Pyuria always implies an area of suppuration in some part of the genito- 
urinary tract, and is generally associated with symptoms referable to its 
location. 

Malformations and Malpositions of the Bladder. — The bladder may 
be absent, the ureters opening into the urethra, the vagina, the rectum, 
or the umbilicus. It may be multiple, single, with a central septum 



672 



THE GENITO-URINARY ORGANS 



dividing it into two portions, which may or may not communicate with 
each other, or sacculated. 

The usual malformation is exstrophy, or absence of a portion of I he 
bladder wall, usually the anterior one. It is most often observed in male 
children, and is due to failure of the lateral portions of the urogenital 
cleft to unite; hence the deficiency is not only of the bladder, but also of 
the musculocutaneous abdominal parietes and the pelvic girdle, the pubes 
not meeting in the middle line to form the symphysis. 



Fig. 434 




Exstrophy of bladder and epispadia. 



This deformity is associated with epispadia in the male and split clitoris 
in the female. There is also commonly associated with it complete 
double inguinal hernia, rudimentary prostate, and ectopic testes. 

The diagnosis is obvious, the bulging, dark red surface of intensely 
inflamed mucous membrane surrounded by an area of cicatrix-like 
tissue uniting its borders to the skin being sufBciently characteristic. 
Projections marking the ureteral orifice can usually be found by the escape 
of urine which comes from them in jets. 

Occasionally, as a congenital defect, the urachus remains patent, the 
urine escaping through the umbilicus. In this mucous channel urinary 
concretions and suppurating pouches may form and may persist after 
closure of the communication with the bladder. 

Hernia of the Bladder .^ — Hernia implies a protrusion of the bladder wall 
along the track usually taken by intestinal hernia. The inguinal cysto- 
cele is the common form, though there are instances of obturator, crural, 
and perineal vesical hernia. The herniated portion of the bladder usually 



THE BLADDER 673 

presents thin walls and is often surrounded by considerable fat. Some- 
times it appears as a diverticulum with an extremely small opening into 
the general vesical cavity. Because of stagnation of urine in these diver- 
ticula calculi may form. 

These hernia are caused by the peritoneal pull of a preceding intestinal 
hernia, and are characterized by a dull, fluctuating tumor in the inguinal 
region, varying in size with the quantity of urine contained in the bladder. 
Where the communication between the herniated portion and the general 
cavity is small there may be no immediate change in the size of the herni- 
ated portion on micturition. If, however, the patient lies down and sub- 
jects the mass to gentle manipulation it markedly diminishes in size, and 
almost immediately he can pass a further quantity of urine. Furthermore, 
the flaccid and inconspicuous swelling becomes tense and full when 
fluid is forced into the bladder. 

As a rule, the herniated portion of the bladder is small and offers no 
symptoms other than those associated with an irreducible omental hernia. 
It is usually unexpectedly encountered during hernia operations. Its 
presence should be suspected when in the effort to close the hernial orifice 
an undue amount of fat is brought into sight. These vesical hernias are 
rarely invested with a complete layer of peritoneum. 

Traumatisms. — Wounds of the bladder, if large and open, are char- 
acterized by the escape of urine through them. If small, by the passage 
of bloody urine, and by the results of cystoscopic examination, together 
with a consideration of the nature of the vulnerating body and its direc- 
tion of travel. Usually there is temporary retention of urine. 

The complications of these wounds are peritonitis, pelvic cellulitis, 
fistulse, and calculi ; the latter from the lodgement of a foreign body in the 
bladder too. large to be passed per urethram. If there be free bleeding 
from the bladder, this in itself is indicative of wound and would justify 
an exploratory operation. 

Contusion of the bladder is characterized by retention, tenesmus, pain, 
tenderness, and the passage of blood-stained urine and clots following 
traumatism. Shock is usually wanting. It is possible that in a previously 
diseased bladder hemorrhage may have been severe and continued. Con- 
tusion with such symptoms is extremely rare. 

The diagnosis must be made from rupture. Theoretically, this can 
be done by injecting a measured quantity of fluid into the bladder and 
withdrawing it. If all that has been injected flows through the catheter, 
it is obvious there can be no large rent in the wall. 

Rupture of the Bladder. — Rupture of the bladder is particularly common 
in drunkards. Probably because they are frequently subjected to trauma 
and often have overfull bladders. It is observed as a result of fracture 
of the pelvis and kicks in the belly. Occasionally it is caused by muscular 
action, such as defecation, urination, or heavy lifting. It has occurred 
at times from moderate distention of a bladder lifted forward by an 
inflated bag in the rectum, with the idea of facilitating a suprapubic 
cystotomy. The rupture may be intraperitoneal or extraperitoneal, 
usually the former. 
43 



674 THE GENITO-URINARY ORGANS 

The characteristic symptoms are a sense of something having ruptured, 
agonizing hypogastric pain, constant desire to urinate, with either the loss 
of power to do so or the passage of blood-stained urine, and severe 
shock. In the course of hours, sometimes days, there will follow either 
the symptoms of general peritonitis or of pelvic cellulitis, dependent upon 
the seat of rupture. 

There may be no immediate symptoms other than temporary inability 
to urinate, and later the passage of bloody urine. Nor does the extrava- 
sation of a small amount of sterile urine inevitably cause peritonitis or 
septic cellulitis. 

Diagnosis is founded upon the symptoms and the results of direct 
examination. 

After flushing the anterior urethra with an antiseptic solution a sterile 
silver catheter of as large size as can be passed is introduced into the 
bladder. If this draws off bloody urine and clot, the probability of rup- 
ture is strong. If, on manipulation of the shaft, so that the tip is made 
to traverse the inner surface of the bladder, this tip repeatedly catches 
at one point, and apparently can be passed through the bladder wall, 
so that it can be felt immediately beneath the skin in the hypogastric 
region or close to the rectal mucous membrane, there can be no doubt 
as to the presence of rupture. Through the silver catheter, after it has 
drained the bladder of its contents, a measured quantity of sterile salt 
solution can be injected. If there be no rupture, this should all flow 
out again. This test is not infallible. Doubt should be resolved by 
suprapubic cystotomy. The cystoscope will be most serviceable in dis- 
proving the existence of rupture, since for its successful use the bladder 
must hold four ounces of a clear fluid. 

Cystitis. — Cystitis, or inflammation of the bladder, is due to infection. 
It is extremely difficult to infect the normal, properly vascularized mucous 
membrane of the bladder. When this becomes greatly congested, as from 
retention of urine, infection is made easy. 

As it appears clinically, cystitis may be acute or chronic, and in 
accordance with the depth of the structures involved it may be catarrhal 
or interstitial. 

The causes of vesical congestion are retention of urine, trauma, 
whether this be due to external injury, passage of an instrument, or 
presence of a stone or tumor, surface chilling, frequently repeated and 
straining micturition, abnormal conditions of the urine, constipation, 
prolonged sexual excitement or excess, cardiac weakness, or lesion of the 
central nervous system. 

The exciting cause of cystitis is local infection, usually due to catheter 
infection or urethritis; exceptionally to pericystic suppurating foci, or 
carried by the blood or lymph vessels. Infection by way of the urine 
may take place secondary to involvement of the kidneys, although 
healthy kidneys may eliminate pyogenic organisms. 

The colon bacillus is the usual infecting agent; less frequently the 
pyogenic staphylococci and streptococci and the Bacillus proteus vul- 
garis. Excepting for the trigonum, the vesical mucosa is to an extent 
immune to the gonococcus. 



THE BLADDER 675 

All the pyogenic germs and many others found in the urine of cystitis 
produce ammoniacal fermentation, providing the urine is retained 
more than a few hours in the bladder. This increases the irritating 
effect of retained urine upon the already inflamed vesical mucous mem- 
brane. Ammoniacal urine is diagnostic of infection and of at least 
partial retention, though this may occur in the renal pelvis. 

The symptoms of cystitis are those of posterior urethritis, except that 
in acute cases there is marked suprapubic tenderness. 

The frequent painful passage of purulent urine constitutes the major 
symptom. In chronic cases pyuria may be the only symptom. 

With the pus there is often found blood and always an excess of mucus 
and bladder epithelium. 

When, together with pain, frequency, urgency, and pyuria the bladder 
is tender on suprapubic and rectal palpation, when the urine passed in 
three portions shows greatest pus turbidity in the last, when the flat 
bladder epithelium is very abundant, when intravesical injections show 
that the bladder is hypersensitive to tension, and when the urine at the 
time of being passed is ropy and ammoniacal, the diagnosis of cystitis 
can be safely made. A large amount of mucopus in the urine (settling 
out -§- on standing) in the absence of pyelitis is diagnostic of cystitis. 
Examination with the cystoscope is conclusive. When this is imprac- 
ticable there may be introduced into the bladder a self-retaining 
catheter, so stretched over a carrier that its flange is obliterated. On 
withdrawing the carrier the elasticity of the rubber causes the flange 
to resume its shape. The catheter is then drawn out until the flange 
catches against the internal vesical sphincter, and is secured in place 
by a small weight attached to its free end. The bladder is thoroughly 
washed out with normal salt solution, and the catheter is left in place for 
an hour, the urine which flows through it being collected. Pus in quantity 
found in this urine must come from the bladder, ureters, or kidneys. 

If the kidneys are neither tender nor obviously enlarged, the bladder 
origin of the pus is probable. The infecting organism must be deter- 
mined by microscopic examination of the pus. 

The essential point in the diagnosis of cystitis is to determine its cause. 
Cystitis once started in a bladder subject to retention because of urethral 
obstruction (enlarged prostate, sclerosed internal vesical sphincter, 
stricture) persists until the obstruction is relieved. So long as a bladder 
contains tumor, calculus, or foreign body there is no tendency toward 
cure. In the absence of these causes of chronic congestion or urethral 
obstruction, cystitis has no natural tendency to persist; hence, if after 
removal of the apparently predisposing factor the infection remains 
obstinate to treatment, this in itself constitutes a good reason for sus- 
pecting tuberculosis. 

Vesical Calculus. — The large majority of calculi are formed of uric 
acid and the urates,. the phosphatic and mixed calculi come next in order 
of frequency, and last come the oxalates and rarer forms. 

Vesical calculi are found from fetal life to old age. They are commonest 
in poor male children and rich old men, and are at times preceded by 



676 THE GENITO-URINARY ORGANS 

a history of gravel, oxaluria, heavy deposits in the urine, hematuria, 
or renal colic. 

The symptoms characteristic of calculus of the bladder are identical 
with those of posterior urethritis or cystitis. Indeed, the latter is often 
the lesion which causes the pain. Frequent urination is most marked 
in the daytime, is aggravated by motion, and relieved by rest. In the 
case of small, freely movable stones urination may be accompanied by 
so much tenesmus as to produce prolapse of the bowel, or there may 
be sudden stoppage of the urine during the passage of a full-sized 
stream, which may be obviated by having the patient assume the dorsal 
decubitus during urination. This symptom is suggestive, though not 
diagnostic, since inflammation in itself may produce reflex spasm causing 
the same symptom. 

The pain of vesical calculus, usually referred to the end of the penis, 
or more accurately to the lower urethral surface, about an inch behind 
the glans, is also common to posterior urethritis. This symptom is not 
observed in old prostatics suffering from stone, because the backward 
projection of the prostate prevents the calculus from coming in contact 
with the vesical neck. It is especially marked in children and induces 
in them that characteristic pulling on the penis which, when associated 
with rectal prolapse, crying during urination, frequency of the act, and 
pus and blood in the urine, is diagnostic of stone. 

The pain of stone is usually terminal, as is the hematuria, which is 
slight. The pain may be referred to the perineum, hypogastric region, 
the small of the back, the outer surfaces of the thighs, the lower leg, or 
the foot. 

The congestion incident to stone predisposes to infection, which is 
usually produced by instrumentation. 

The diagnosis is based upon physical examination, since stone may 
exist in the absence of all these symptoms, even blood not being found 
on microscopic examination of the urine. 

The examination is conducted by bimanual palpation The patient 
having passed his urine, is directed to lean well forward with the elbows 
on a table or the hands resting on a chair, with the legs moderately 
separated and the abdominal muscles relaxed. Thereafter he is placed 
upon his back with the shoulders and the thighs flexed. In each position 
the index finger of one hand is passed into the rectum, the fingers of the 
other press above the pubis. In children a stone of moderate size can 
be felt. A large stone can nearly always be detected in adults unless 
there is an associated prostatic hypertrophy. 

Instrumental examination is inaugurated by an antiseptic irrigation of 
the anterior urethra. Thereafter a stone searcher, fully 10 inches long, 
with a short curve near the tip, is introduced. This searcher should be 
hollow, to permit of evacuation of the bladder contents. When the 
searcher is first passed the bladder should be well distended; as the 
examination proceeds the urine should be allowed slowly to flow out. 
When using this instrument the patient is placed in the flat dorsal posi- 
tion. When the prostate is greatly enlarged and the bladder not greatly 



THE BLADDER 677 

distended, he is put in the Trendelenburg posture. The introduction 
of the curve of the instrument within the bladder is usually painful and 
requires that its shaft should be depressed well below the horizontal plane 
of the body. The searcher has not satisfactorily entered the bladder 
until at least eight inches of its shaft have passed within the meatus 
and it can be rotated almost completely about its long axis without the 
slightest sense of resistance. 

The bladder having been entered, the sound is pushed backward 
and drawn forward again with comparatively rapid motions, the handle 
being elevated and depressed and carried first to one side, then the 
other. It is at no time sufficiently withdrawn to engage the curve of 
the instrument in the prostatic urethra. Failing thus to detect the 
stone, the sound is introduced to its full extent, and its tip is flicked 
from side to side by a rapid rotary motion of the handle. This 
motion, begun with the inner end of the sound at the bas-fond, is con- 
tinued while the sound is gently drawn outward until the curve reaches 
the vesical neck. If the stone is not found in this manner, the tip is 
again introduced as far as it will go, is turned gently toward the floor 
of the bladder and rotated quickly from side to side, while the instru- 
ment is gradually withdrawn until its curve catches the vesical neck. 
The anterior w^all of the bladder may be explored by pressing it down by 
suprapubic pressure until the tip of the instrument can reach its surface. 
When there is an enlarged prostate and the base of the bladder is de- 
pressed, it is well to elevate this portion of the viscus by a finger intro- 
duced into the rectum, while the exploration with the sound is continued. 

If these manipulations fail to detect the stone, the urine should be grad- 
ually withdrawn and they should be repeated as the bladder contracts. 
A sharp click denotes the presence of a stone. It is both felt and heard. 

This examination may fail to detect the stone because it is small, 
encysted, lies in a diverticulum, is fixed by adhesions to the anterior 
wall of the bladder, is covered with lymph or blood clot, or is lodged in a 
pocket or sinus lying between the vesical mucosa and the prostate. 

The click may be simulated by incrustation of a tumor with lime salts, 
by a fasciculated and incrusted condition of the bladder. 

If there is reason to suppose the calculus is a small one, as when a 
recent ureteral colic shows it has not been long in the bladder, the exami- 
nation should be conducted with the small tube of an evacuating litho- 
trite. The bladder is distended, in the case of an adult with four to 
six ounces of fluid, the evacuator of the lithotrite is filled with protargol 
solution, 1 to 2000, the tube is introduced into the bladder, connected 
with an evacuator, and the stopcock is turned on. Then by squeezing 
the bulb of the evacuator one or two ounces of fluid is injected into the 
bladder; on relaxing the pressure a similar quantity is rapidly sucked 
out. This will draw a small stone into the eye of the evacuator, making 
a sharp click. The eye of the evacuator should be carried systematic- 
ally into various portions of the bladder in making this examination. 

Cystoscopic examination conducted by an expert in the use of the 
instrument is to the surgeon the most satisfactory way of making a 



678 THE GEN IT 0-U BINARY ORGANS 

diagnosis. To the patient the x-tslj is the easiest way and is fairly 
rehable in its results. 

Foreign Bodies in the Bladder.— Foreign bodies in the bladder 
may cause no symptom until they become complicated by cystitis, when 
incrustation with urinary salts promptly occurs. The symptoms are 
those of stone, from which a differentiation can be made only by the 
ic-rays or cystoscopic examination. Often the history is diagnostic. 

Tuberculosis of the Bladder. — Nearly always secondary to infection of 
the kidneys, it may be unsuspected until microscopic examination of the 
urine shows the presence of blood and mucus, with an excess of leuko- 
cytes greatly deformed and free from bacteria. Usually there is a noc- 
turnal and diurnal frequency not sufficiently pronounced to excite 
attention. At times there is slight terminal hematuria obvious to the 
patient. 

With the onset of cystitis, which almost inevitably develops and is 
frequently incident to the first catheterization practised for diagnosis of 
the cause of frequency, there is pain, greatly aggravated by the act of 
micturition, urgency, pyuria, and either microscopic or macroscopic 
blood. The pain of tuberculous cystitis is more harassing, persistent, 
and obstinate to treatment than that from any other cause, with the 
exception of calculus. It is due in great part to spasm. The coincident 
loss of weight and deterioration of physical condition are partly incident 
to pain, but mainly to the accompanying tuberculous nephritis. 

Diagnosis is based upon finding the tubercle bacilli, often a difficult 
matter, elimination of other causes, and cystoscopic examination. 
This may show disseminated or grouped tubercles or ragged, irregular 
punched-out ulcers. Usually in the trigonum in the neighborhood of 
the ureter. Characteristic family history and tuberculous involvement 
elsewhere are suggestive evidence. 

In the absence of direct bladder examination, apparently causeless 
and persistent bladder irritability or cystitis is in itself strongly suggestive. 

Tumors of the Bladder. — ^Tumors of the bladder, usually observed 
in middle-aged men, may be benign or malignant. 

Benign tumors are usually papillomata. Next in order of frequency 
come the myxomata, or polypi. Adenomata, fibromata, and cysts are 
reported. 

The malignant growths include sarcomata, carcinomata, and mixed 
tumors. 

Carcinoma. — Carcinoma is the commonest of all bladder tumors, 
including both the benign and malignant. The tumor is usually placed 
in or about the trigonum, though it may be found in any portion of the 
bladder surface. Sometimes it is pedunculated, usually sessile, and is 
infiltrating. 

The characteristic symptom is sudden, causeless, profuse hemorrhage 
stopping as quickly as it started. If the last part of the urine passed 
contains more blood than the first part, and if instrumental examination 
of the bladder always occasions free bleeding and demonstrates that the 
tip of the instrument is arrested at some point in its sweep, the diagnosis 



THE URETERS 679 

of vesical tumor is well assured. Absolutely so if with the blood clots 
fragments of the growth of sufficient size for microscopic examination 
are passed. Pain, frequency, and urgency are usually not noted until 
the bladder tumor is compHcated by cystitis, and are then symptoms 
of the latter condition and not of the tumor. 

If a cystoscope can be passed without occasioning obscuring bleeding, 
it will usually afford a view of the lesion sufficiently clear to be diagnostic 
both as to nature and position. 

A recurring vesical bleeding so free and so easily excited as to prevent 
the use of the cystoscope calls for diagnosis by suprapubic cystotomy, 
since the only hope of cure lies in early operation. The passage of 
irregularly shaped clots, superabundance of bladder epithelial cells, 
absence of fragmentation in the blood corpuscles, and absence of kidney 
albumin are all indicative of the vesical origin of hemorrhage. The 
most severe and frequently recurring hemorrhage may come from a 
small papilloma. 

Benign tumors untreated may lead to a fatal termination, either from 
an exhausting hemorrhage or ascending pyelonephritis. The course of 
these cases is extremely slow (many years). 

Malignant tumors are also slow (years) both in growth and metastasis. 



THE URETERS. 

The ureters are musculomucous canals about twelve inches long, passing 
behind the peritoneum from the renal pelvis to the bladder. The normal 
points of narrowing are about two inches below the pelvis of the kidney, 
at the crossing of the iliac artery and near the vesical orifice. The ureters 
are capable of enormous dilatation as the result of chronic blocking. 
Even though not dilated, they can be stretched to 16 F. without tearing. 
The vesical portion of the ureter runs obliquely inward and forward for 
half an inch through the muscular layer of the bladder wall, opening by 
a slit-like orifice, the upper wall of which is devoid of muscular fibers, 
and so thin that intravesical tension produces a valvular closure. 

Anomalies of the Ureter. — These channels may be absent or multiple; 
in the latter case either fusing or passing separately into the bladder. 
The double ureter is commonly associated with a kidney with two pelves. 
The ureters may pursue an aberrant course, opening at the external 
urinary meatus into the vagina or at the umbilicus. 

Valve formation is a common cause of hydronephrosis. The ureter 
may pass from the pelvis of the kidney at an acute angle or may run for 
some distance in the wall of this reservoir in place of escaping from the 
funnel-shaped orifice at its lowest portion. 

Rupture of the ureter is characterized by extravasation of urine. If the 
urine is sterile, this need not lead to cellulitis. Small effusions will be 
absorbed. If the extravasation be continuous, a large fluctuating tumor 
may develop. Rupture of the ureter is ultimately followed by stricture 
and hydronephrosis. 



680 THE GENITO-URINARY ORGANS 

The diagnosis is made by the history of trauma of such nature as to 
expose the ureter to injury, followed by the formation of a fluctuating 
tumor in the lumbar region unattended with the symptoms of internal 
hemorrhage. If this on aspiration is found to be urine the diagnosis is 
assured. When the rupture is not sufficiently extensive to cause a 
demonstrable urinary extravasation the later development of a hydro- 
nephrosis will prove the existence of a previous ureteral injury. 

Wound of the Ureter. — ^Wound of the ureter during a surgical operation 
is usually recognized both by the escape of urine and because the thick- 
walled white cord is readily recognized. Ligation of the ureter is fol- 
lowed in rare instances by signs of mild renal colic. As a rule, symptoms 
are wanting unless both ureters are ligated, in which case there is 
anuria Diagnosis in any suspected case is made by the cystoscope 
failing to show escape of urine from the ureteral orifice and by the 
ureteral catheter encountering the obstruction. 

Ureteritis, predisposed to by congestion, such as would be caused by 
traumatism, lodgement or passage of a calculus or clot, the passage of 
irritating urine or distention from any obstruction, is caused by infection 
which may ascend from the bladder or descend from the kidney. Excep- 
tionally it comes from without, as in the case of an inflamed appendix 
adherent to the peritoneum overlying the ureter. The symptoms are 
indefinite, and are usually obscured by the accompanying pyelitis or 
cystitis. 

The diagnosis may be suggested by urethral tenderness on palpation. 
This tenderness will be found by making deep pressure at the point of 
intersection of a line joining the anterior superior iliac spines with a 
vertical line running upward from the junction of the inner and middle 
thirds of Poupart^s ligament. Such tenderness is not, however, pathog- 
nomonic of ureteritis. 

Stricture of the ureter may be congenital or acquired. The symptoms 
are those of back pressure, i. e., hydronephrosis and dilatation of the 
ureter above the seat of narrowing. 

The diagnosis may be made by ureteral catheterization, a point of 
narrowing being found which, after having been passed by the ureteral 
catheter, will yield a free flow of urine. 

The presence of hydronephrosis not due to stone, movable kidney, or 
the pressure of a pelvic tumor, or to chronically distended bladder, is 
suggestive of ureteral stricture. 

Calculus of the Ureter. — ^The majority of calculi, having once entered 
the ureter, pass into the bladder without symptoms. When the stone is 
of such size or shape that it cannot immediately pass, it is arrested at 
one of the points of narrowing, usually just above the bladder or in 
the intravesical portion of the ureter. 

Ureteral calculus is usually single, at times multiple, exceptionally 
bilateral. The immediate symptoms of an arrested or slowly progressing 
ureteral calculus are those of renal colic. The remote symptoms, if the 
arrest be continuous, are hydro- or pyonephrosis. Exceptionally hydro- 
nephrosis incident to renal calculus develops without history of preceding 



THE URETERS 681 

acute pain. During the attack of colic the urine will contain no blood 
unless the obstruction is incomplete. With the subsidence of severe 
pain blood appears in the urine, often only microscopically. 

Typical renal colic, which will be caused by any sudden ureteral obstruc- 
tion and consequent renal tension, is characterized by the sudden onset 
of agonizing pain, located in the lumbar and hypochondriac regions and 
radiating therefrom along the course of the ureter, to the end of the penis, 
to the testicle of the affected side, to the inner surface of the thigh. The 
pain is sufficiently severe to cause marked shock, at times collapse. It 
is attended with abdominal tympany, vomiting, and tenderness, urgent 
desire to micturate, with loss of power to do so, and tenderness, elicited 
by deep pressure in the angle made by the last rib and the erector spinse 
muscles, or from before backward just below the tenth costochondral 
junction. 

Exceptionally the pain may radiate to the chest or shoulders or be 
referred to the unaffected kidney. 

The distinction from acute fulminating peritonitis must be made by 
the absence of rigidity, the seat of tenderness on pressure, the finding 
of blood in the urine, radiations of pain to the penis and testicle, and 
interference with bladder function when the stone is lodged in the pelvic 
portion of the ureter. 

When anuria develops, this is evidence of bilateral renal disease, 
probably but not necessarily calculous. 

After the subsidence of an acute renal colic, or in the absence of this, 
a stone lodged in the intravesical portion of the ureter will cause frequent, 
urgent, painful micturition and usually pus in the urine, i. e., the symp- 
toms of posterior urethritis. 

The diagnosis, unless it be suggested by a history of repeated renal colics 
followed by the development of a hydronephrosis or pyonephrosis, must 
be made by cystoscopic examination, showing an inflamed patulous 
ureteral opening from which the stone may project as a tumor. Ureteral 
sounding will demonstrate the presence of obstruction, and, if a bougie 
with a wax end should be used, it will possibly show markings incident 
to impact against the calculus. 

The a;-rays, on which from a diagnostic standpoint the main reliance 
must often be placed, may be misleading, since phleboliths and caseating 
glands give pictures much like those of ureteral stone. Multiple shadows 
should always be distrusted, and this is particularly so if they are not 
placed strictly in the line of the ureter or if the patient examined be 
suffering from genito-urinary tuberculosis. 

The persistent lodgement of a stone in the ureter or the pelvis of the 
kidney, unattended with hydronephrosis or pyelonephrosis of such extent 
as to be palpable, has been mistaken for chronic appendicitis and 
cholecystitis. 

The presence of blood and pus in the urine and the downward radia- 
tions of pain during the acute attacks are characteristic. 

Ureteral fistulse are characterized by a steady or irregular flow of 
urine. They are kept up by stricture and show little tendency toward 



682 THE GENITO-URINARY ORGANS 

spontaneous cure. Cystoscopic examination and ureteral catheterization 
may be needful to exclude the vesical origin of such fistulse. 

Tuberculosis of the ureter can be diagnosticated only by the develop- 
ment of obstructive symptoms. It is masked by the associated tubercu- 
losis of the bladder and Iddney. 

The ureteral papilla is the most frequent seat of cancer. This can 
be diagnosticated only by cystoscopic examination. The first symptom 
of growths situated elsewhere in the ureter would probably be those 
of obstruction, though unusually free bleeding from the passage of a 
ureteral instrument might suggest papilloma. 



THE KIDNEYS. 

The kidneys are placed in the upper back part of the abdomen, behind 
the peritoneum, and, if normal in size and position, cannot be felt. In 
people of relaxed fiber, particularly women who have lost much fat, the 
right kidney is, as a rule, distinctly palpable on deep expiration. 

The lower poles of both kidneys lie above the umbilicus. A vertical 
line carried up from the middle of Poupart's ligament to the costal arch 
should cross the kidney at about the junction of the middle and inner 
thirds. 

Surgical diseases of the kidney are characterized by displacement, pain, 
tumor, pus, blood, and renal elements in the urine, lessened permea- 
bility, and the systemic manifestations of toxemia or infection. 

The simplest and most satisfactory proof of renal permeability is the 
passage of an adequate quantity of urine containing a normal percentage 
of urea. 

Since surgical intervention is usually directed to one kidney, it is of 
cardinal importance if the nature of the malady be such as to require 
nephrectomy (malignant growth, tuberculosis, pyonephrosis), that there 
be a functionally competent kidney on the other side. 

The existence of two kidneys may be determined by a;-rays, and 
almost certainly, except when the kidneys are fused, by ureteral cath- 
eterization. 

Permeability, i. e., functional activity of each organ, can be absolutely 
assured only by ureteral catheterization and examination of the secre- 
tion thus obtained from each kidney. When one kidney is obviously 
extensively diseased and renal excretion is satisfactorily maintained, 
it is probable that the remaining and apparently healthy kidney is 
adequate to its function. 

The phloridzin test is based upon the power of the normal kidney 
to eliminate sugar within a certain time after the subcutaneous adminis- 
tration of phloridzin. In renal disease the appearance of sugar in the 
urine is delayed and the elimination is feeble, prolonged, or absent. 

Cryoscopy, or determination of the freezing point of the urine, is an 
elaborate procedure, requiring from 10 to 20 c.c. of this fluid. Its 
compensating value is questionable. 



THE KIDNEYS 683 

The passage of the ureteral catheter will sometimes inhibit the flow of 
urine for from ten to thirty minutes. 

Anomalies. — The kidneys may depart from the normal in number, 
shape, size, position, attachment, and mobility. 

The absence of one kidney has been noted with sufficient frequency 
to warrant the surgeon in assuring himself of the presence of both kidneys 
before performing nephrectomy. This defect is more common on the 
left than on the right side. A single kidney is large. Fused kidney may 
assume the shape of a horseshoe or may be fused along the whole inner 
surface, forming one large oval or rounded organ, with bloodvessels and 
excretory ducts attached to its centre or possibly to one side. It may 
reach enormous size, simulating abdominal tumor. 

The kidney may be displaced from its normal position in any direction 
except posteriorly. The displacement is usually downward, the kidney 
lying in the region of the sacroiliac articulation. It may be tilted, 
rotated, or turned on its own axis. 

A displaced kidney, often fixed in its false position, usually causes no 
symptom. 

Floating kidney is a congenital anomaly in which the organ is loosely 
attached to the posterior abdominal wall by a mesonephron. The 
diagnosis can be suspected from the free mobility, but can be assured 
only by operation. 

Movable Kidney. — The kidney is normally movable, falling and rising 
with each respiratory act. 

It may be capable of excursions much greater than those recognized 
as normal or may lie permanently below its proper level without exhibit- 
ing symptoms. This condition is common in thin, long-bodied neuras- 
thenic women with an obsession for doctors. 

Movable kidney, when it becomes a surgical affection, is characterized 
by renal colic sudden in onset, recurrent, with associated gastro-intestinal 
symptoms. This colic is sometimes relieved by position, is associated 
with albumin, hyaline casts, and sometimes blood in the urine, with 
palpable tenderness of the kidneys, and is followed by hypersecretion of 
urine. Hepatic colic, dilatation of the stomach, and gastric catarrh 
have been attributed to the drag of the right kidney, while intestinal 
indigestion has been attributed to movable left kidney through partial 
blocking of the descending colon. 

The diagnosis of movable kidney is made by direct palpation. The 
patient is placed in the dorsal decubitus, with the thighs flexed, head and 
shoulders elevated, and the trunk slightly inclined toward the side to be 
examined by a thin pillow placed under the opposite loin. The fingers 
of one hand are placed posteriorly just below the twelfth rib, those of the 
other hand in front below the costal margin, over the lower pole of the 
kidney. The patient is directed to breathe deeply. By gradually 
increasing the bimanual pressure the examining fingers are sunk deeply 
down until the kidney is felt in its inspiratory descent. In women, 
particularly those who are emaciated, the normal kidney can often be 
felt on the right side. When, however, the kidney descends so far during 



684 THE GENITO-URINARY ORGANS 

inspiration that its expiratory ascent can be prevented by firmly pressing 
above it with the examining fingers, the mobihty is abnormal. The 
gravity of the affection, however, is dependent, not upon the freedom 
of mobility, but upon the presence of symptoms produced by it. 

In distinguishing the kidney from other tumors its characteristic shape 
and the completeness with which it can be pressed back into the normal 
position are highly characteristic. 

From omental growths and tumors of the colon, movable kidney can 
be distinguished by the fact that it lies behind these. 

Dilatation of the gall-bladder presents the greatest diagnostic difficulty. 
The tumor is, however, obviously anterior and continuous with the 
liver, cannot be made to recede into the loin, and, if subject to attacks of 
colic, is tender to superficial anterior pressure and does not give down- 
ward pain radiation attended or followed by blood in the urine. Nor 
can it be made distinctly more prominent and accessible by pressure in 
the loin. When palpation leaves the examiner in doubt, the affection is 
usually one of the kidney. 

Contusion of the Kidney. — Contusion of the kidney may be caused by 
direct or indirect violence, as from kicks, blows, pressure or contortion, 
flexions of the trunk, or by violent jarring from a fall. 
' Direct violence is usually inflicted by a narrow vulnerating body, since 
the kidney is protected against broad pressure. The lesion, usually 
complicated by trauma of neighboring organs, varies from subcapsular 
ecchymoses and intrarenal blood extravasation to extensive rupture. 
Intrarenal bleeding is rarely profuse. Extrarenal hemorrhage may be fatal. 
The symptoms are hematuria, and usually shock and severe sickening 
pain, followed by the formation of lumbar tumor if there be extrarenal 
bleeding. 

Hematuria may be absent if the ureter be ruptured, slight if the hemor- 
rhage be mainly extracapsular or parenchymatous, or profuse. Hemor- 
rhage so severe as to threaten life is usually intraperitoneal or perinephric. 
The urine often contains worm-like clots moulded into this shape by the 
ureter, and, because of the blocking caused by these clots, attacks of renal 
colic may supervene. Recurrent hemorrhage is not uncommon. 

The characteristic sickening renal pain is more marked in contusions 
characterized by slight ecchymosis than in extensive lacerations, nor is 
immediate shock a reliable index as to the extent of renal lesion. 

Lumbar tumor developing in a few hours is due to blood. If it in- 
creases from day to day without inflammatory symptoms other than those 
normal to a clean wound reaction, it is probably due to urine which may 
be retained in the renal pelvis or may be extravasated into the perirenal 
tissue, forming a false hydronephrosis. 

Renal Calculus. — Renal calculus may be single or multiple. It is 
usually irregular in shape and of uric acid. Next in order of frequency 
are the oxalates. Both these stones are deposited from acid urine. 
Calculi made up of phosphate or carbonate of lime are deposited from 
alkaline, usually infected, urine. 

Calculus is usually found in the renal pelvis or its branches. Excep- 



THE KIDNEYS 685 

tionally it is placed in the substance of the kidney. In the absence of 
infection the calculus is generally adherent, taking the shape of the por- 
tion of the pelvis in which it is placed; at times bifurcating or branching 
like a piece of coral, representing a mould of the pelvis and its subdivi- 
sions. In about 15 per cent, of ca^'jes both kidneys are affected. 

The uric acid, the oxalate or the phosphatic diathesis and local infection 
are predisposing factors. They favor coagulation necrosis of cells, thus 
furnishing the organic framework essential to calculus formation. 

The affection may be without symptoms. Usually it is characterized 
by pain in the back just below the twelfth rib and in front over the posi- 
tion of the kidney, attacks of renal colic, renal tenderness, testicular 
or ovarian hyperesthesia of the affected side (Bittorf), hematuria, renal 
albumin, hyaline casts, and gastro-enteric disturbances. 

The characteristic pain is an ache, aggravated by bodily activity and 
repeated jarring. Subject to acute exacerbations, which may occur at 
night, waking the patient. These exacerbations may take the form of 
acute renal colic attended by vomiting, tympany, and collapse, exhibiting 
downward radiations along the course of the ureter and into the genitals. 
Exceptionally the pain is referred to the healthy kidney. 

During the periods of exacerbation, often at all times, there is renal 
tenderness elicited by deep palpation. 

Hematuria is usually detected only on microscopic examination, is 
intermittent, and is markedly increased by jarring or bodily activity. 
Exceptionally it is transitorily profuse, apparently causeless, and is sub- 
ject to recurrence at long intervals. Frequent urination is a common 
reflex, though it is more essentially a symptom of calculus lodged in 
the ureter. Passage of gravel or fragments of calculi are symptoms of 
great diagnostic value. 

Temporary suppression of urine may occur during attacks of renal 
colic. This, when it persists for several days, is indicative of bilateral 
disease. 

The gastro-intestinal disturbances, i. e., distaste for food, tardy stomach 
digestion, flatulence, constipation, and diarrhea, may be reflex. They 
are usually, however, expressions of toxic absorption. 

When stone in the kidney becomes complicated by infection, this is 
indicated by pus in the urine and marked aggravation of all the symp- 
toms, especially those of gastro-intestinal disturbance. Pyelitis is sug- 
gestive of stone simply because it is such a common sequel of this 
condition. 

Of these symptoms, pain and hematuria are the two most constant and, 
with the exception of the passage of calculus fragments, the most char- 
acteristic. 

The absolute diagnosis is made by the a;-rays, or, this failing, by 
exploratory incision. 

The a;-rays afford the most trustworthy means of making the diagnosis. 
The picture must be clear and unmistakable, and repetitions must show 
a correspondence in the shadow or shadows in at least two pictures 
taken at different times. In the case of uric acid calculi the a:-rays may 



686 THE GENITO-URINARY ORGANS 

fail. Hence, if symptoms are persistent, with signs of progressing renal 
degeneration or infection, the diagnosis must be made by direct incision. 

The symptoms of renal calculus may be closely simulated by neph- 
ralgia, crises of locomotor ataxia, oxaluria, phosphaturia, chronic 
interstitial nephritis or tuberculosis of the kidney, movable kidney, 
cholecystitis, or appendicitis. 

Nephralgia, oxaluria, phosphaturia, and strongly acid urine may all 
be characterized by renal tenderness, blood in the urine, and pain with 
paroxysmal exacerbations radiating downward. Nephralgia occurs in 
neurasthenic females, is worse at the time of the catamenia, is charac- 
terized by the passage of large quantities of urine of low specific gravity, 
and very exceptionally the urine contains a few blood corpuscles. 

The dull pain and slight hematuria of oxaluria or phosphaturia are 
transitory in nature, and disappear completely under appropriate treat- 
ment. These conditions are, however, often associated with calculus. 

Crises of locomotor ataxia, which may exactly simulate renal colic, are 
suggested by the history of the case and other symptoms of cord degenera- 
tion, nor is there blood found in the urine either during or after the attack. 

Tuberculosis may exhibit precisely the symptoms of stone. The 
finding of the tubercle bacillus will be diagnostic. It ultimately 
becomes complicated by tuberculosis of the bladder, but the diagnosis 
should be formed before this develops. Tuberculous lesions elsewhere 
would be suggestive. Mixed infection develops earlier than is the case 
with calculus, hence an apparently causeless pyelitis in the absence of 
preceding symptoms of long standing (months or years) is suggestive 
of renal tuberculosis. 

Movable kidney must be distinguished by the detection of this condition 
by direct examination. Aside from the mobility the symptoms may be 
identical. 

Gallstone colic gives upward and backward radiation. Tenderness 
is marked on superficial pressure over the region of the gall-bladder, 
there is an abundant secretion of urine not containing blood and there 
is no difficulty in passing urine. The preceding history is often char- 
acteristic. 

Appendicitis may simulate renal colic. In the acute attack the 
location of the point of greatest tenderness is characteristic and mus- 
cular rigidity is not found in renal colic, though this may be simulated 
by the voluntary resistance of the patient during examination. If the 
appendix be adherent to the ureter or point downward, involving the 
bladder, the vesical symptoms may exactly simulate those of renal or 
ureteral irritation. The blood will, however, be absent from the urine. 
Nor can renal tenderness be elicited by deep dorsal pressure beneath 
the last rib. 

The distinction between ureteral and renal calculus may be suggested 
by tenderness along the course of the ureter and marked vesical symp- 
toms. It can be made positively only by the ir-rays and by exploration of 
the ureter at the time of operation. This should always be done when the 
kidney is opened, particularly if the ureter is dilated. 



THE KIDNEYS 687 

Suppurative Diseases of the Kidney. — Predisposition is offered by 
renal congestion, the ordinary cause of which is back pressure from 
obstruction in any part of the urinary tract. Exposure to cold; trauma- 
tism; drug irritation, such as that incident to irritating diuretics, anti- 
septics, balsams, and ethereal oils; chronic interstitial nephritis; gastro- 
enteritis; gout; pregnancy; the mechanical irritation of gravel or calculus; 
irritation of elimination in acute infectious diseases, and tuberculosis 
are common predisposing factors to infection. 

The usual microorganisms of renal suppuration are the Bacterium 
coli communis, the Staphylococcus aureus, the Streptococcus pyogenes, 
and the Proteus hauseri. Exceptionally the gonococcus, the typhoid 
bacillus, the pneumonia diplococcus are the caustive agents. 

Infection may reach the kidney through the blood in the course of 
elimination. This is the common route when suppurative inflammation 
occurs in the course of infective fever. It may extend to the kidney from 
inflammation of adjacent structures. It is usually secondary to infec- 
tion of the bladder, ascending by way of the ureter. 

The infection may take the form of a pyelitis, which, if complicated 
by obstruction, becomes a pyelonephrosis, the inflammation reaching 
its maximum in the pelvis of the kidney. When both the pelvis and 
the renal parenchyma are extensively involved the affection is called 
pyelonephritis. This is the form usually taken by an ascending 
infection. Suppuration of the renal substance secondary to systemic 
infection, and entering by the blood channnels, may be without char- 
acteristic symptoms until the rupture of an abscess into the renal pelvis 
or the perirenal tissue causes a sudden pyuria or a perinephric abscess. 

The characteristic symptoms of renal infection are pain in the lumbo- 
dorsal region, fever which may be exceedingly high and accompanied 
by chills and sweats, renal tenderness on deep palpation, and pus of renal 
origin in the urine. This point may be determined by ureteral catheter- 
ization or inspection of the urinary jet as it escapes from the ureter. 

Pyelitis. — Usually bilateral, it is even in its acute outbreak often 
obscured by the symptoms of an antecedent disease, such as gastro- 
enteritis, typhoid, pneumonia, or la grippe infections, or by those of 
acute or chronic cystitis. 

In its acute form it is characterized by severe pain in the region of the 
kidney, tenderness on palpation, frequent urination, with decrease in the 
total quantity, and often vomiting, fever, chills, and sweat. The urine is 
usually acid, contains a trace of albumin, degenerated epithelium, hyaline 
casts, mucus, pus, and often blood. 

Chronic pyelitis may be attended with no symptoms other than pus in 
the urine and is often overlooked, particularly in children. Diagnosis 
depends upon the examination of the urine secured by ureteral catheteriza- 
tion. Usually there is kidney ache, some slight local tenderness on deep 
pressure, and general impairment of health and slight toxic anemia. 
The urine, usually acid, contains polynuclear leukocytes, nucleo-albumin 
(from the pus and blood), and is increased in amount. The casts are of 
the hyaline variety. There are frequently recurring subacute attacks. 



688 THE GENITO-URINARY ORGANS 

Intermittent pyuria, i. e., pus disappearing from the urine for some 
hours and then recurring, shows that the inflammation is confined to one 
side, and that pyonephrosis is developing on that side. 

In the absence of acute obstruction and its attendant renal colic, poly- 
uria and pyuria are the most diagnostic features. Nocturnal frequency 
is regarded by Bazy as highly characteristic. 

Pyonephrosis. — Pyonephrosis is a sequel of pyelitis and back pressure, 
or is caused by infection of a hydronephrosis. In the former case there 
is usually a history of renal infection associated with recurring attacks 
of renal colic, often the presence of a palpable, tender tumor, with the 
fever and sweats of either acute or chronic sepsis. 

The tumor, if present, lies behind the colon, can be felt by bimanual 
palpation, is freely movable, but slightly tender, except during attacks of 
colic, exceptionally distinctly fluctuating, and varies in size from time to 
time. This, together with intermittent pyuria, or, more commonly, 
marked variations in the quantity of pus, is a highly characteristic 
feature. 

Exceptionally a pyonephrosis develops with almost no symptoms 
other than those of impaired health and toxic anemia. The dis- 
tinction from hydronephrosis is made by urinary examination and by 
the absence of constitutional symptoms in cases of simple urinary 
retention. 

Pyelonephritis. — Pyelonephritis is the usual sequel of pyonephrosis, 
the suppuration involving and destroying the kidney parenchyma. 
The acute form of infection is characterized by lumbar pain and violent 
septic symptoms, i.e., prolonged chills, high fever, and drenching sweats, 
associated with an irritable condition of the stomach, characterized by 
persistent vomiting and hiccough. The associated symptoms of intoxica- 
tion are those of sepsis and uremia. The prognosis, though extremely 
bad, is not absolutely so, there being a possibility of the pus collections 
draining through the ureter. 

Chronic pyelonephritis is characterized by pus in the urine, and a 
tpxic condition exhibited by complete anorexia, dry tongue, scanty 
secretion of saliva, tympany, constipation, often uncontrollable diarrhea. 
Intercurrent acute febrile attacks develop. There may be no pain or 
other local symptoms, the diagnosis of the affection being entirely 
dependent upon the examination of the urine. There is usually polyuria, 
except in the terminal stage, and constant pyuria subject to marked 
quantitative variations. At times necrotic fragments of renal substance 
are passed, often preceded by renal colic from temporary blocking of the 
ureter. Frequently repeated severe attacks of renal colic suggest the 
complication of renal calculus. 

The distinction between cystitis and pyelonephritis is made by ureteral 
catheterization, though chronic cystitis produces very little systemic 
effect. 

When the underlying lesion of a pyelonephritis is tuberculous, this 
may be suggested by tuberculous lesion elsewhere. If the bacillus 
can be recovered from the urine, this will be diagnostic. Mere per- 



THE KIDNEYS 689 

sistence of the infection in the absence of obstruction or calculus is 
strongly suggestive. 

Acute hematogenous nephritis, usually unilateral, is characterized by 
the rapid development of septic symptoms. Chills, fever, and sweats, 
with rapid and at first sthenic pulse, abdominal tympany and tenderness, 
but without rigidity, and tenderness on deep pressure at the costo- 
vertebral angle. The urine at first may show only a trace of albumin 
and a few red blood cells. Later, if the patient survives, when abscesses 
form and break into the pelvis, there will be pus in quantity. The 
swollen kidney can sometimes be felt. Early diagnosis is based upon 
violent septic symptoms and the seat of local tenderness. Occurring on 
the right side the affection strongly suggests appendicitis. 

Perinephric Suppuration. — Perinephric suppuration, which may be 
traumatic in origin or secondary to renal suppuration or infection of 
neighboring organs, particularly the appendix, is commonest in middle- 
aged men. 

The pus usually discharges in the lumbar region or passes upward 
toward the pleural cavity, causing, first, a serous effusion, later an 
empyema. It may burrow into the pelvis behind the peritoneum, 
may pass down within the sheath of the psoas muscle, or may rupture 
into the ureter, kidney, colon, duodenum, or stomach. 

The affection is characterized by pain, tenderness, and fever, and a 
fixed, vaguely outlined, rapidly progressing tumor in the lumbar region. 
When the affection is not masked by a preceding causative lesion, such 
as appendicitis, pyelonephrosis, or lumbar osteomyelitis, the diagnosis 
is readily formulated. The pain is aggravated by motion of the thigh 
of the affected side and the body is curved toward this side. The 
thigh is sometimes flexed and adducted, and there is marked poly- 
morphonuclear leukocytosis, except when the abscess is purely tuber- 
culous secondary to bone involvement. Frequently there is tympany 
and vomiting. 

Spinal tuberculosis will usually be noted by its slow onset and by 
associated symptoms. A neoplasm fixed in position can be difterentiated 
from pure perinephric abscess only by its comparatively slow and 
progressive growth and by the absence of septic symptoms and pyuria. 

Hydronephrosis.- — Hydronephrosis, due to obstruction to the flow of 
urine through any portion of the urinary tract, may be congenital or 
acquired. It may be persistent or intermittent, unilateral or bilateral, 
partial or total. Partial hydronephrosis involves one or more calices, 
but not the whole pelvis. 

Bilateral hydronephrosis is incident to obstruction low down in the 
urinary tract. Enlarged prostate, hypertrophy of the bladder from 
urethral obstruction, and tumors of the pelvic organs compressing the 
ureters are common causes. 

The usual causes of unilateral hydronephrosis are calculus and mov- 
able kidney. Valve formation and irregular implantation of the ureter 
into the renal pelvis are unusual causes. Even postmortem examina- 
tion has at times failed to detect a cause. 
44 



690 THE GENITO-URIN'ARY ORGANS 

The secreting substance of the kidney ukimately disappears from 
pressure atrophy and interstitial nephritis incident to interference 
with the circulation. 

The diagnosis of hydronephrosis is based upon the finding of a smooth, 
rounded, movable, fluctuating tumor placed behind the colon, unat- 
tended with fever, pain, or tenderness. 

The intermittent form of the disease is characterized by the recurring 
development of a tumor, accompanied usually by renal colic and by the 
rapid diminution in size or disappearance of this tumor attended with 
polyuria. After attacks of renal colic, the urine may contain blood, 
albumin, and hyaline casts. 

When the hydronephrosis is well developed (containing many gallons), 
distinction from cystic growths, particularly those of ovarian origin, 
can be made only by the history of the case. The presence of urinary 
salts usually proves the origin of the fluid. These may be absent when 
the renal parenchyma has atrophied. 

Tuberculosis of the Kidney. — ^Tuberculosis of the kidney may appear 
in its acute form as a part of general miliary tuberculosis. The symp- 
toms are then masked by the general systemic invasion. 

Chronic renal tuberculosis may appear as the sole evidence of tuber- 
culous invasion, or may be secondary to lesions of the lungs, bones, or 
other parts of the body. It is commonest in early manhood, and in 
its beginning is unilateral. The second kidney is ultimately involved 
by the infection which first invades the bladder, then blocks the ureter 
of the healthy side, and finally reaches this kidney predisposed to infec- 
tion by the congestion incident to blocking and prolonged elimination 
of toxic substances. 

The diagnosis in the early stage of the affection is based upon a con- 
stant or intermitting ache in the renal region, deterioration in general 
health, polyuria and frequent urination not otherwise explicable, slight 
(usually microscopic) transitory, apparently causeless, hematuria, and 
demonstration of tubercle bacilli in the urine. 

The existence of lesions obviously tuberculous in other parts of the 
body, particularly in the genito-urinary tract, and tuberculous family 
history are sufficiently common to be of diagnostic value. The tuber- 
culin test may be serviceable. 

When the disease is fairly well advanced and involves the pelvis of 
the kidney, hyaline and granular casts appear and the descending 
infection involves the ureter, the renal orifice of which becomes edema- 
tous, hyperemic, and sometimes eroded. 

On the advent of mixed infection, which develops earlier than is the 
case with stone, the symptoms of pyelitis and pyelonephritis or pyelo- 
nephrosis develop. This, in the absence of other causative lesion, is 
suggestive of tuberculosis. As the affection progresses perinephric 
abscess is a common complication. 

The determination as to whether one or both kidneys is affected 
usually depends upon ureteral catheterization and the injection of the 
urine drawn from each kidney into susceptible animals. 



THE KIDNEYS 691 

Syphilis of the Kidney. — Syphilis of the kidney may manifest itself 
in the form of a congestion, shortly (weeks) following the chancre, 
characterized by a slight, transitory, intermittent albmninuria, with 
possibly hyaline casts. 

In the secondary period (the first two years of the disease) acute 
parenchymatous nephritis may develop, dependent upon the syphilitic 
virus or its toxins, exhibiting the symptoms of this condition when it is 
due to other causes and cured by specific treatment. 

In the later stages of the disease (after two years) interstitial nephritis 
may develop. 

Aneurysm of the Renal Arteries. — ^Aneurysm of the renal arteries is 
characterized by the formation of a postperitoneal tumor, following 
traumatism; either exhibiting no symptoms or characterized by profuse 
bleeding into the pelvis of the kidney or into the peritoneal cavity. 

The diagnosis is made by surgical operation or autopsy, since the 
tumor is so deeply placed that neither thrill, bruit, nor pulsation can 
be detected. The possibility that a renal tumor which shortly follows 
traumatism and is accompanied by profuse hematuria may be an 
aneurysm should be considered. 

Tumors of the Kidney. — ^Tumors of the kidney are commonest in 
children under five years of age, usually sarcomatous, are characterized 
by profuse, intermittent, and apparently causeless hematuria (at times 
associated with transitory colic from ureteral blocking by clots), a sense 
of weight or pain in the lumbar region, and the formation of a rapidly 
growing postperitoneal tumor, always prominent in the loin, though its 
direction of growth may be either upward, forward, or both. 

The tumor is usually fixed, hard, bossed, and, if small, lies behind the 
colon. If it attains large size, this viscus may be pushed completely to 
one side. 

Hypernephroma, constituting the large majority of renal tumors 
observed in the adult, exhibits the clinical features of sarcoma; recurring, 
apparently causeless, often profuse bleeding, and the development of 
tumor. The favorite seats of metastasis are the long bones, the liver, 
and the lungs. 

In the late stages of malignant disease of the kidney the huge size 
of the growth, its rapid progression, dilated veins of the abdomen, and 
profound cachexia make the nature of the affection unmistakable. Diag- 
nosis should be based upon the results of operation performed when free 
bleeding without obvious cause first suggests the probability of neoplasm. 

The lateral position of the tumor and the lumbar bulge usually enable 
a distinction to be made from retroperitoneal sarcoma. The diagnosis 
from renal calculus and from renal tuberculosis will be suggested by 
the slight bleeding characteristic of the latter conditions. 

Papilloma. — Papilloma of the renal pelvis (rare) is characterized by 
hematuria or, if it becomes obstructive, pain. It is diagnosticated only 
by surgical operation. 

Cystic disease of the kidneys (congenital) is characterized by bilateral 
enlargement of slow growth (years) unattended with hematuria, There 



692 THE GENITO-URINARY ORGANS 

is usually associated moderate hydronephrosis. Such kidneys are sub- 
ject to nephrolithiasis and pyelitis. 

The diagnosis is based upon the slow enlargement, this distinguishing 
it from sarcoma. The bosselated surface of the tumor, its failure to 
be distinctly outlined by the x-rays, and the symptoms of a progressive 
renal incompetency are characteristic features. The diagnosis is usually 
made post mortem. 

Hydatid cyst may be distinguished from hydronephrosis only by 
direct examination, excepting in the case of rupture into the pelvis or 
ureter, when the examination of the urine should be diagnostic. 

The Adrenal Glands. — The adrenal glands, if diseased bilaterally 
and extensively (tuberculosis), are attended with emaciation, anemia, 
adynamia, vomiting of blood, melena, and often bronzing of the skin 
(Addison's disease). 

Tumor of the suprarenal capsule usually cannot be diagnosticated 
from similar conditions involving the kidney excepting by the absence of 
blood from the urine. Even this may be present incident to pressure, 
congestion, or direct renal involvement. The adrenal tumor in its growth 
displaces the kidney downward, and may be first felt in the epigastric 
region to the right or the left of the middle line. General and pro- 
nounced outgrowth of hair and hypertrophy of the genitalia have been 
noted. Metastasis to the orbital region is characteristic of one form 
of sarcoma. 

Cysts of the suprarenal gland (rare), of slow growth (years), and 
probably secondary to embolus or hemorrhage, form thoraco-abdominal 
tumors, the origin of which even operation has at times failed to demon- 
strate. 



CHAPTEE XIX. 

GYNECOLOGICAL DL\GNOSIS. 
By BROOKE M. ANSPACH, M.D. 

Gynecological diagnosis depends upon the history, the symptoms, 
and the physical examination. To correctly determine each of them, 
one must be familiar with the normal anatomy of the reproductive 
organs, with the various gynecological diseases, and with both the sub- 
jective and the objective manifestations of pelvic disorders. 

The Anatomy of the Reproductive Organs. — The genital organs 
may be divided for the purpose of description into the external, the 
intermediate, and the internal genitalia. The external genital organs, 
collectively known as the vulva, are bounded by the labia majora, the 
pubes, and the perineal body. The vulva comprises the labia majora, 
the labia minora, the clitoris, the external urinary meatus, the vestibule, 
the hvmen, the ostium vaginse, and the fourchette. It is covered with a 
modified skin which is thinner than the general cutaneous covering, and 
contains sebaceous and sudoriferous glands. 

The vulvovaginal glands are two distinct bodies, each about the size 
of a bean, embedded in the lower part of the labia majora, on either 
side of the introitus vaginae. The ducts open upon the vulvar surface 
about the middle of the vaginal orifice and just in front of the hymen. 
The secretion is mucous. The perineal body lies between the vaginal 
introitus and the anus. It is the musculofibrous intersection of the 
transversus perinei, the bulbus cavernosum, the levator ani, and the 
sphincter ani muscles. At the external urinary meatus are two invagi- 
nations of the urethral mucosa known as Skene's tubules. They are 
each about f of an inch in length and open on the urethral surface just 
within the meatus. In the multiparous women the orifices are visible 
as small openings of sufficient size to admit a bristle. 

The vagina extends from the vulva to the cervix, which it surrounds 
and to w^hich it is attached. The ballooned-out upper part of the vagina 
into which the cervix projects is known as the vaginal fornix. The 
vaginal walls in the normal nulliparous woman are in contact, except 
at the introitus and at the vaginal fornix. The posterior wall is held 
against the anterior wall by the support it receives from the levator ani 
and the other muscles and fasciae of the pelvic floor. The anterior 
border of the levator ani muscle can be felt in the normal woman just 
within the vaginal orifice, on either side, its fibers forming a band 
about one-half inch in thickness. The vagina is lined by a modified 
skin very much like that of the vulva and containing no glands. It 
is moistened bv the so-called vasfinal secretion which consists of the 



694 GYNECOLOGICAL DIAGNOSIS 

discharge from the cervix and the uterus, desquamated epithehum, 
and transuded blood serum. 

The cervix projects into the vaginal fornix. It is covered by a 
reflection of the vaginal mucosa as far as the external os, where the 
mucosa of the cervical canal begins. It has a smooth, grayish red 
appearance. The external os is usually plugged with clear, thick mucus. 
The cervix points toward the coccyx and its axis is nearly at right 
angles to that of the vagina. 

The body of the uterus is flexed gently forward upon the cervix 
and lies within the cavity of the true pelvis. Its anterior surface is in 
relation with the superior surface of the bladder. As the bladder fills 
with urine, the fundus of the uterus is pushed upward and backward. 

The pelvic peritoneum covers the anterior and the posterior surface 
of the uterus, dipping down between the body of the uterus in front to 
about the level of the internal os, and then being reflected forward upon 
the bladder. Posteriorly the peritoneum covers the entire surface of the 
uterus and thence is reflected to the pelvic wall, partially surrounding 
the rectum. The peritoneal space thus formed between the uterus and 
the rectum is known as Douglas' pouch. 

The tubes and ovaries lie at the side of and posterior to the uterus. 
They are held in position by the broad ligaments which run from the 
lateral borders of the uterus to the pelvic wall, and by the uteroovarian 
and the infundibulopelvic ligaments. The outer extremities of the tubes 
are open and communicate with the peritoneal surface of the pelvis. 
The ovary is not covered by the peritoneum, but projects from the 
posterior peritoneal surface of the broad ligament. 

The uterine ligaments consist of the broad, the uterosacral, the utero- 
vesical, and the round ligaments. All of these but the last mentioned 
are formed by foldings of the pelvic peritoneum, enclosing between them 
fatty connective tissue, a few muscle fibers, bloodvessels, and nerves. The 
round ligaments are distinct fibromuscular structures which pass from 
the cornua of the uterus through the inguinal canals to the pubes. 

The body of the uterus is lined by a mucous membrane known as the 
endometrium. It is continuous with the mucosa of the cervical canal 
at the internal os and with that of the tubes at the uterine cornua. 
Within the tube the mucosa is thrown into folds and at the outer 
extremity projects into the peritoneal cavity as a fringe-like formation, 
spoken of as the fimbria. 

GENERAL CONSIDERATION OP THE HISTORY AND OF THE 

SYMPTOMS. 

The age and the social position of the patient may direct the physician 
to a certain extent in collecting the data for a diagnosis. 

Diseases Occurring before the Age of Puberty. — Only a few gynecologi- 
cal diseases are found before the age of puberty. Gonorrheal vulvo- 
vaginitis, malignant tumor (cystic or solid) of the ovary, grape-like 
sarcoma of the cervix, and tuberculous salpingitis and peritonitis are 



CONSIDERATION OF THE HISTORY AND SYMPTOMS 695 

those most often encountered. Sometimes a catarrhal inflammation 
of the tube occurs during the course of one of the acute exanthematous 
diseases; ovaritis may compHcate mumps, scarlet fever, or smallpox. 
These complications produce abdominal pain which is usually mis- 
interpreted and the disease escapes attention. At some time subse- 
quently, however, the result of the pelvic inflammation may become 
manifest in hydrosalpinx, adherent adnexa, or adherent retroposition 
of the uterus; sterility may be caused by light velamentous adhesions 
covering the tubal ostia. Congenital malformations, except gross 
deformities of the external genitalia, do not become noticeable, as a 
rule, until puberty. 

Diseases Occurring after Puberty and during Adolescence. — ^Affections 
which manifest themselves at puberty are either the result of a mal- 
formation of some part of the genital apparatus or an evidence of general 
ill-health. Thus, a tumor arising from any of the forms of gynatresia 
(hematocolpos, hematometra, hematosalpinx), or subjective evidence 
of functional or anatomical insufficiency of the genitalia (amenorrhea, 
dysmenorrhea) may appear. Malignant tumor (cystic and solid) of 
the ovary, grape-like sarcoma of the cervix, and tuberculosis of the tubes 
and of the pelvic peritoneum are more frequent than before puberty. 

As adult life is approached, gonorrhea and pregnancy are encountered 
in the married and in the non-virginal. 

Diseases Occurring between the Ages of Twenty-one and Forty in the 
Unmarried and Virginal. — The various lesions due to gonorrheal infection 
and to pregnancy and childbirth may be excluded. Dysmenorrhea of 
the neuralgic type, the result of a lowered general body tone, may develop 
in those who lead an unhygienic life. 

Neurasthenia and the various neuroses will be met, the subjects fre- 
quently having a fixed and erroneous idea concerning their pelvic organs. 
A congenital or a traumatic displacement of the uterus may become 
manifest. Endometritis or some general affection may be indicated by 
leucorrhea or menorrhagia. Fibroid tumor and endometrial polyp are 
not uncommon. 

Diseases Occurring between the Ages of Twenty-one and Forty in the 
Married and in the Non-virginal. — ^The whole gamut of disorders caused 
by the gonococcus is found in this class. Pregnancy, normal and path- 
ological, and its results are encountered. Pelvic inflammatory disease, 
displacements of the uterus, lacerations of the cervix and of the pelvic 
floor are common. Fibroid tumors occur, especially in those who have 
been sterile or who give the history of repeated miscarriages. 

Diseases Occurring between the Ages of Forty and Sixty. — ^The diseases 
associated with the menopause and with old age include ovarian cysts, 
carcinoma of the cervix, carcinoma of the fundus, extreme degrees of 
displacement of the uterus, laceration and hypertrophy of the cervix, 
cystocele, and rectocele. Carcinoma of the cervix almost never occurs 
in those who have borne no children. Carcinoma of the body of the 
uterus frequently occurs in sterile women and in combination with 
fibroid tumors of the uterus. 



696 GYNECOLOGICAL DIAGNOSIS 

The Time of Onset of the Symptoms. — ^The time of the onset of the 
symptoms may furnish a clue to the diagnosis. Thus, developmental 
anomalies are first detected at the time of puberty or after marriage. 
Gonorrheal infection and all of its sequelae date from suspicious inter- 
course or from marriage. Gonorrheal endometritis or peritonitis in a 
woman already infected frequently begins at or about the time of the 
menstrual period. The onset of the symptoms of displacement of the 
uterus, laceration of the cervix, and relaxation of the pelvic floor will 
customarily be referred to childbirth. 



GYNECOLOGICAL SYMPTOMS IN DETAIL. 

Pain. — Pain varies in character, location, and time of occurrence. 

Character. — Pain may be dull, sharp, neuralgic, or cramp-like. Dull 
pain is most common in displacements of the uterus and in relaxations 
of the pelvic floor. It may arise also as a result of pressure from a 
pelvic tumor. Dull pain is sometimes associated with a dragging sensa- 
tion in cases of relaxation of the pelvic floor and in displacements of the 
uterus. 

Sharp, lancinatmg pain is usually found in inflammatory affections 
of the pelvic peritoneum and the adnexa. The pain at the time of 
rupture of a tubal pregnancy is often spoken of as lancinating. 

Neuralgic pain is found in diseases which produce compression or 
infiltration of nerve sheaths. The most familiar examples of neuralgic 
pains are found in carcinoma of the cervix (infiltration and compression), 
tumors which block the pelvis (compression), and dense inflammatory 
masses (compression and infiltration). 

Cramp-like pain, or the pain associated with muscular contractions, 
occurs from the efforts of the uterus to expel a foreign body, as, for 
example, a piece of placenta, a pedunculated submucous fibroid tumor, 
or an endometrial polyp. Cramp-like pains also occur from tubal con- 
tractions in tubal pregnancy preceding tubal abortion or rupture. 

Burning pain accompanies acute inflammation of the vulva, vagina, 
and bladder. It is also found in urethral caruncle. 

A sensation of loss of support is complained of in relaxation of the 
pelvic floor. 

Location. — External Genitalia. — ^Pain from inflammatory and other 
affections of the vulva or the vagina is usually felt in the external 
genitalia, perineum, and groin. 

Bladder. — ^A burning pain with frequency of urination may be found 
in inflammatory affections of the urethra and the bladder, in relaxation 
of the pelvic floor, in prolapsus of the uterus with cystocele, in retro- 
position of the uterus, in fibroid tumor (pressure on the bladder), and 
in pelvic inflammatory diseases of all types when the bladder is involved. 
Frequent and painful urination which is due to displacement of the 
uterus or relaxation of the pelvic floor disappears when the organs are 
replaced and maintained in good position. 



GYNECOLOGICAL SYMPTOMS IN DETAIL 697 

Pain in the Rechim. — A feeling of pressure and pain in the rectum 
is found in cases of rectocele, especially during attempts at defecation. 
In extreme degrees of retroposition, when the body of the uterus presses 
against the bowel, the patient may complain of a sensation as if a foreign 
body were in the rectum. An intense desire to defecate is often associated 
with pelvic hematocele. Pain during defecation is sometimes observed 
in prolapsus of the ovary. 

Pain in the lower abdomen in the median line is found in relaxation of 
the pelvic floor, in pathological anteflexion, retroposition, and prolapse 
of the uterus, and in uterine fibroids, especially of the intramural or the 
submucous type. 

Pain in the lower abdomen at the sides is found in pelvic inflammatory 
disease and in tubal and ovarian affections such as extra-uterine preg- 
nancy, cystic ovary, prolapsed ovary, and ovarian cyst. 

Backache in the sacral region, vertical headache, and pain along the 
front or the back of the thighs are referred sensations, and may be 
present in a variety of gynecological diseases. Backache is especially 
prone to be associated with relaxation of the pelvic floor and displace- 
ment of the uterus. The same may be said of vertical headache. Pains 
which are referred to the thighs are the result of pressure on the sciatic, 
the obturator, or the crural nerves, and may be produced by any tumor 
or inflammatory affection. 

The Time of the Occurrence of Pain. — Pain due to a relaxation of the 
pelvic floor and to a displacement of the pelvic organs is less when the 
patient is in bed; it gradually increases when the patient gets up and 
goes about or works. The pain is always relieved by assuming a recum- 
bent position. 

Rheumatic pain in the back and limbs is worse on arising from bed, 
and becomes less as the muscles of the back and thighs are called into 
use. 

Inflammatory pain is but little influenced by rest, unless it keeps 
inflamed surfaces apart or reduces muscular tension over inflamed 
areas. 

Menstrual Symptoms. — The menstrual symptoms which are met in 
gynecological diseases are amenorrhea, scanty menstruation, acute 
suppression of the menstrual flow, menorrhagia, metrorrhagia, and 
dysmenorrhea. 

Amenorrhea is an absence of menstruation. This term does not 
apply to the absence of menstruation during pregnancy. Nor can it 
be truly used in cases of retention of the menstrual flow because of an 
imperforate hymen or in any form of gynatresia (hematocolpos, hemato- 
metra, hematosalpinx). In such instances the flow occurs, but is not 
visible for obvious reasons. 

xAmenorrhea may depend upon an anatomical lesion of the uterus 
or of the ovaries which renders menstruation impossible, e. g., hyper- 
involution of the uterus; ovaritis complicating parotitis, scarlet fever, 
or smallpox; bilateral sarcoma or carcinoma or atrophy of the ovary 
or fatty degeneration of the ovary associated with general obesity. 



698 GYNECOLOGICAL DIAGNOSIS 

Amenorrhea may be the result of diseases which affect the general 
health, such as chlorosis, typhoid fever, tuberculosis, myxedema, Base- 
dow's disease, diabetes, carcinoma outside of the genital tract, gastric 
catarrh, leukemia, acromegaly, or Addison's disease. 

Amenorrhea may have a psychical cause, such as the fear of impreg- 
nation, the desire for impregnation, terrible fright, altered social rela- 
tions, or a change of climate. 

Scanty menstruation is etiologically similar to amenorrhea. The 
cause is less active in the case of scanty menstruation. 

Suppression of the Menstrual Flow. — ^A sudden cessation of the men- 
trual flow occurs as the result of wet feet or of insufficient clothing for 
the lower extremities. Sea-bathing, the use of a cold douche, and psychic 
influences will also produce it. The menstrual flow sometimes ceases 
abruptly during an attack of gonorrheal endometritis or peritonitis. 

Menorrhagia is an increase in the amount or the duration of the 
menstrual flow. 

Metrorrhagia is a uterine hemorrhage which occurs between the men- 
strual periods. It is to a large extent dependent upon the same causes 
as menorrhagia. Metrorrhagia represents the extreme effect of a cause 
which may have first produced menorrhagia. The causes of menor- 
rhagia and metrorrhagia are general and local. 

The general causes are: Cardiac incompetency, cirrhosis of the 
liver, interstitial nephritis, the hemorrhagic diathesis, scurvy, typhoid 
fever, cholera, variola, scarlatina, influenza, acute articular rheumatism, 
and syphilis, secondary or tertiary. 

The local causes are: Endometritis, endometrial polyp, subinvolution 
of the uterus, relaxation of the uterine muscle, retrodisplacement of the 
uterus, fibroid tumor, carcinoma or sarcoma of the uterus, tubal pregnancy, 
cystic degeneration of the ovary, and carcinomatous ovarian tumors. 

The source and the cause of menorrhagia and metrorrhagia should 
be investigated in every instance. It should be remembered that 
metrorrhagia is usually the first symptom of cancer. This symptom in 
a woman past forty years of age should always arouse the greatest 
anxiety until malignant disorders are excluded. 

Dysmenorrhea is a word used to designate pain of varying type and 
location which is definitely associated with the menstrual flow. Dys- 
menorrhea usually signifies sharp, cramp-like pain in the lower abdomen. 
But severe headache and backache and dull pain in the hips and ovarian 
regions also constitute a form of dysmenorrhea. 

Dysmenorrhea may be due to congenital defects such as infantile type 
of uterus, ill-developed fundus, long, conical or short, knob-like cervix, 
or sharp anteflexion or stenosis of the cervix. Congenital defects of the 
nervous mechanism may also be responsible for the neuralgic type of 
dysmenorrhea. 

Dysmenorrhea may be symptomatic of almost any of the acquired 
pelvic lesions, e. g., endometritis, retroposition of the uterus, fibroid 
tumor of the uterus, uterine polyp, inflammatory diseases of the adnexa, 
ovarian tumors, etc. 



GYNECOLOGICAL SYMPTOMS IN DETAIL 699 

Dysmenorrhea, the result of obstruction to the cervical canal, ante- 
flexion, stenosis, etc., commonly consists of cramp-like pain in the lower 
abdomen which precedes the menstrual discharge from twenty-four to 
thirty-six hours and is relieved as soon as the flow is well established. 
In dysmenorrhea associated with fibroid tumor, endometrial polyp, 
endometritis, or retroposition of the uterus, the pain starts with the 
flow and continues throughout the period. 

Dysmenorrhea from chronic pelvic inflammatory disease or cystic 
degeneration of the ovaries takes the form of a dull, heavy ache in the 
lower abdomen and hips which precedes the appearance of the menstrual 
flow and then gradually subsides. The neuralgic form of dysmenor- 
rhea may simulate any of these. Usually it partly simulates that due 
to obstruction, viz., the cramp-like pains begin prior to the establish- 
ment of the menstrual flow, but, unlike the obstructive type, they con- 
tinue throughout the period, not being relieved by the escape of the 
menstrual blood. The neuralgic form sometimes consists of a dull, 
heavy sensation in the lower abdomen, the ovarian regions, and the 
thighs, preceding the period, and frightful headache and backache during 
the flow. 

Leucorrhea. — Leucorrhea is a symptom of numerous gynecological 
disorders. It may be mucous, mucopurulent, purulent, or putrid in type. 

Mucous leucorrhea results from catarrh of the vulvovaginal glands 
and the cervix. Cervical mucus is extremely thick and tenacious. 

Mucopurulent leucorrhea results from an infection of the vulvovaginal 
and the cervical glands. As the disease progresses the discharge may 
become purulent. 

Purulent leucorrhea originates from vulvitis, urethritis, vaginitis, ulcer- 
ative diseases of the vulva and the vagina, and acute endometritis. 

Serous leucorrhea, sl thin watery leucorrhea, is noted in chronic endome- 
tritis, in the early stage of some cases of carcinoma of the corpus uteri, 
in fibroid tumor, in early sarcoma of the uterus, in chronic pelvic con- 
gestion, and in constitutional debility. 

Putrid leucorrhea is noted in carcinoma and sarcoma of any part of 
the genital tract, the peculiar odor occurring as soon as infection and 
necrosis of the newgrowth takes place. A sloughing, or necrotic, 
fibroid tumor or endometrial polyp, retained and putrefying secundines, 
or decidual tissue produces the same result. 

Constipation. — Chronic constipation is noted in retrodisplacements 
of the uterus, in fibroid tumors of the uterus, or in other pelvic tumors 
which encroach upon the rectum. Constipation is also noted in pelvic 
inflammatory diseases, both in the acute and in the chronic stage. 

Pruritus Vulvae. — Pruritus vulvae is often indicative of an irritating 
discharge, but it may be a symptom of many disorders. In the severest 
form it is accompanied by local lesions. It is discussed under diseases 
of the vulva on page 708. 

Fever. — Most of the inflammatory diseases are accompanied by fever. 
In acute gonorrhea of the urethra, vulvovaginal glands, and the cervix 
it is usually slight. Abscess of the vulvovaginal glands, acute endome- 



700 GYNECOLOGICAL DIAGNOSIS 

tritis, acute pelvic peritonitis, and acute salpingitis and ovaritis are 
accompanied by a considerable degree of pyrexia. In tubal pregnancy 
(before rupture) there is often some rise of temperature. 

Sterility. — A woman is said to be sterile when conception does not 
occur within three years after marriage. This is an arbitrary statement, 
and is, of course, modified by the condition of the husband and by any 
means which have been used to prevent conception. Relative sterility 
— '^one child sterility" — is the common result of an ascending gonorrheal 
infection occurring in the first and only puerperium. Sterility on the 
part of the woman may be due to imperfect development, inflammatory 
disease and its result, or to some functional or mechanical difficulty 
which renders the sexual act faulty or keeps the spermatic particles 
from meeting the ovum. 

Developmental Sterility. — The following defects may prevent impreg- 
nation: Hyperplasia of the ovaries (few and imperfectly formed ova), 
fetal type of Fallopian tube (the tube is long and very much twisted), 
diverticula of the tubal canal (ovum is caught in a blind passage and 
arrested in its progress toward the uterus), infantile or fetal type of 
uterus (the fertilized ovum is badly embedded and perishes), stenosis 
of the cervix (spermatic particles cannot enter the uterus), elongation 
of the cervix and flattening of the vaginal fornices (the semen is expelled 
from or runs out of the vaginal vault almost directly after it is deposited 
there), malformation of the vagina or the external genitalia (normal 
intercourse or the entrance of the spermatic particle is difficult or 
impossible). 

Sterility Depending on Pelvic Inflammatory Diseases. — Any inflam- 
matory disease which closes the abdominal ostia of the tubes or produces 
kinking and contraction of the lumen of the tube may lead to sterility. 
Dense adhesions of the ovary prevent rupture of the Graafian follicles, 
cervical gonorrhea destroys the spermatozoon or prevents its ingress; 
endometritis renders difficult the embedment of the ovum after it has 
been fertilized. 

Salpingitis and ovaritis complicating the exanthemata in early life 
may result in thin velamentous adhesions about the tubal ostia. 

Mechanical impediments to the ingress of the spermatic particles, such 
as acute anteflexion or retroflexion, fibroid tumor, or adenomatous polyp, 
may account for sterility; a lacerated or an everted cervix may prevent 
conception because of the displacement of the external os. 

Functional sterility may be due to vaginismus or to incompatibility 
between the male and the female. 



METHODS OF EXAMINATION. 

The same methods of examination which are employed for physical 
diagnosis in general are used in gynecology. On account of the 
anatomy of the parts, certain positions are required in order to satisfac- 
torily conduct the examination, and certain instruments or devices are 



METHODS OF EXAMINATION 



701 



of service. While the physical examination includes inspection, pal- 
pation, percussion, and auscultation, the most valuable are inspection 
and palpation. Percussion is useful in the diagnosis of pelvic tumors 
which encroach upon the abdominal cavity. Auscultation is scarcely 
ever used except in the diagnosis of pregnancy. Palpation is the sine 
qua non of gynecological examinations. Inspection is a valuable aid 
and should precede the others. 

Position of the Patient. — For a routine examination the dorsal ^position 
is the best. The patient lies upon her back with the thighs well flexed 
upon the abdomen and the knees widely separated. The legs are flexed 

Fig. 435 




Dorsal position. Bimanual or abdominovaginal examination. 



on the thighs and the feet are held either by stirrups suspended from 
upright rods, or by foot-rests at the end of the examining table. The 
buttocks should project slightly over the edge of the table. If necessary, 
the patient can be examined in bed. She should lie across it with her 
buttocks resting on the edge, the shoulders and head elevated by a 
pillow, the knees widely separated, drawn upward, and supported by 
assistants. 

Sims' Position; Knee-chest Position — The Sims position or the knee- 
chest position is advisable when inspection of the vaginal vault or of 



702 



GYNECOLOGICAL DIAGNOSIS 



the anterior vaginal wall is desired. These positions are also of value 
in cystoscopic or in proctoscopic examinations. In Sims' position, 
the patient lies on the left side with the left arm behind her; the trunk 
is rotated so that the front of the chest lies in contact with the table; 
the thighs are flexed at right angles to the abdomen and the legs at 
right angles to the thighs; the right thigh is flexed more than the left, 
so that the right knee lies above the left. A small, firm pillow placed 
beneath the hips will increase the efficiency of this position by securing 
greater inclination of the pelvis. In assuming the knee-chest position. 



Fig. 436 




Knee-chest position. 



the patient kneels upon the edge of the table, sinking the chest to the 
surface and spreading the arms to either side, the elbows being flexed; 
the face is turned to one side. The thighs must be vertical, the chest 
must rest upon the table, the spinal column must be relaxed, and the 
lumbar curve exaggerated. 

Position for Abdominal Examination. — When pelvic disease causes 
distention of the abdomen, or in any case of abdominal enlargement 
when pelvic disease is suspected, an examination of the abdomen 
should follow the pelvic examination. For this purpose the patient 
should lie flat on her back with the knees and the shoulders slightly 
elevated by pillows. 

Preparation of the Patient for an Examination. — ^The sigmoid flexure 
and the rectum should be thoroughly evacuated. The bladder should 
be emptied voluntarily or by catheterization, except in a case where 
it is especially desirable to observe the presence, the nature, and the 
amount of a leucorrheal discharge. Under such circumstances a pre- 
liminary inspection should be made several hours after urination or 
defecation. A douche should never be given previous to the first gyne- 



METHODS OF EXAMINATION 703 

cological examination. The clothing about the waist should be loosened. 
Constricting bands should be unfastened. 

Armamentarium. — Lubricant. — ^A very satisfactory lubricant for the 
fingers in pelvic examinations is composed of 

Gum tragacanth 3v to gr. xlviij 

Carbolic acid TTj^ xxxij 

Glycerin 3iij 

Water Sxxxij 

Petroleum jelly or oil may be used; it protects the fingers more than 
a watery paste, but is harder to wash off and is more objectionable to 
the patient. Whatever lubricant is chosen, it should be expressed 
from a collapsible tube or poured upon the fingers. 

Rubber Gloves. — ^The hand should be protected by a rubber glove 
whenever infection of any sort is probable in a vaginal examination, and 
always in digital palpation of the rectum. The transference of infec- 
tion from the vagina to the rectum or vice versa should be carefully 
avoided. 

Specula. — ^Howard's or Graves' bivalve, or Nott's trivalve speculum, 
is used in the dorsal position. In the Sims or in the knee-chest position 
the Sims speculum is required. Every speculum should be well lubri- 
cated before it is inserted. It should be introduced with its greater 
diameter in the oblique axis of the vagina and then turned to the desired 
position. The bivalve and the tribladed specula hold the vaginal walls 
apart, exposing the cervix and that part of the vaginal surface which 
lies between the blades. The Sims speculum retracts the posterior 
vaginal wall and favors atmospheric distention of the vagina, the 
patient being in the knee-chest or the Sims position; in this way the 
entire anterior vaginal wall, the cervix, and the vaginal vault are exposed. 

As a rule, examination of virginal women should be made under the 
influence of an anesthetic. Palpation should be made per rectum. If 
inspection of the cervix is necessary, a large-sized Kelly cystoscope or 
the smallest trivalve speculum may be used. 

Pelvic Examination. — Inspection of the external genitalia should be 
the first step in a pelvic examination. The existence of a leucorrheal 
discharge and the presence of venereal sores or any other lesions of the 
vulva may be detected in this way. Inspection will often give at once 
certain valuable information. For example, a virginal introitus will 
exclude the diseases due to pregnancy and childbirth; a reddening of 
the orifices of Skene's tubules and of the ducts of the vulvovaginal 
glands will suggest gonorrheal infection. An imperforate hymen will 
explain an absence of the menstrual flow. Extensive lacerations of the 
perineum, cystocele, rectocele, etc., are often revealed at a glance. 

The cervix and the vaginal fornices are exposed by means of a speculum. 
The state of the vaginal mucosa, whether bathed in leucorrheal discharge 
or bereft of its natural moisture, and the presence of erosions or inflam- 
mation can be observed immediately. The contour of the cervix 
the amount and the character of the cervical discharge^ and any gross 



704 GYNECOLOGICAL DIAGNOSIS 

lesions may be detected. Inspection of the cervix aside from the mere 
question of cervical diseases gives evidence concerning the parity of 
the woman and the probability of a chronic gonorrheal infection. 

Palpation. — ^Evidence of gonorrheal infection may be shown by 
"milking'"* Skene's tubules and the vulvovaginal glands. The friability 
and the induration of a cancerous growth, the peculiar disk-like hard- 
ness of a chancre, the fluctuation of a vulvovaginal cyst, or the tender- 
ness and induration of an inflammatory affection may be noted. The 
condition of the perineal floor, the presence of cystocele and rectocele, 
and the spastic contraction encountered in cases of vaginismus may 
be detected. The friability of a cervical outgrowth, softening or indu- 
ration of the cervix, or an abnormality in the diameter of the cervical 
canal — all may be quickly ascertained. 

Palpation of the vaginal vault yields further information. In front of 
the cervix the sharp kink of an anteflexion may be recognized; the body 
of the uterus may be felt through the posterior vaginal fornix in well- 
marked cases of retroposition and often also an angle of flexion between 
the cervix and the body. An ovary prolapsed into Douglas' pouch is 
at once detected. 

While this simple digital examination gives a considerable amount of 
information, no examination is complete without bimanual palpation. 
By this means the pelvic organs are picked up between the palpating 
hands one after the other, and an estimate is made of their size, mobility, 
consistency, and sensitiveness. The feasibility of a satisfactory bimanual 
palpation in a given case will depend upon the degree of relaxation of 
the abdominal muscles which the patient is able to induce voluntarily, 
and upon the amount of adipose tissue in the abdominal walls. Rigid 
or thick abdominal parietes render bimanual examination difficult or 
unsatisfactory unless an anesthetic is employed. 

In bimanual palpation the palmar surface of one hand is placed 
upon the abdominal wall and one or two fingers of the other hand are 
introduced into the vagina or into the rectum. Palpation is made first 
with the organs in the position in which they are found. Afterward, 
except in acute or subacute pelvic inflammatory disease, if it is desir- 
able, bimanual palpation may be made with a finger in the rectum 
while the uterus is drawn downward by means of a tenaculum. This 
maneuver brings the entire posterior surface of the uterus within reach 
of the examining finger and permits a minute examination of the pos- 
terior surface of the broad ligaments and of the pouch of Douglas. 

In bimanual palpation the cervix is located with the vaginal finger 
and the direction of its axis in relation to that of the vagina is noted. 
Normally it is almost at a right angle and points toward the coccyx. 
If it is found in the axis of the vagina it is quite likely that the uterus 
is retroposed or that the patient is suffering from an acute anteflexion 
of the cervix. The body of the uterus is the next objective point. If 
it is in normal position — anteversion and anteflexion — it may be pal- 
pated between the vaginal finger placed upon the anterior vaginal wall 
just in front of the cervix, and the abdominal hand pressed downward 



METHODS OF EXAMINATION 705 

and toward the pelvic outlet in the median line above the symphysis. 
If the fundus is not found by this maneuver, it is evidently out of posi- 
tion. The vaginal finger is now carried back of the cervix along the 
posterior vaginal vault while the abdominal hand is sunk downward 
below the sacral promontory. In case of well-marked retroposition, the 
posterior surface of the body of the uterus will be felt inclining back- 
ward toward the sacrum, and, if retroflexion is present, the angle 
between the cervix and the body can be made out easily. Besides the 
position, the size, consistency, mobility, shape, and sensitiveness of 
the uterus may be determined. 

To palpate the left adnexa, the vaginal finger is carried to the extreme 
left lateral part of the vaginal fornix, and pressed upward along the 
pelvic wall as far as possible while the abdominal hand is gently sunk 
downward and forward over the brim of the true pelvis to the left of 
the sacral promontory. The finger in the vagina and the fingers of 
the abdominal hand are approximated at the highest lateral and pos- 
terior position feasible and then drawn gently forward. By this means 
the normal ovary and tube are brought between the fingers. The 
normal ovary feels like a smooth, elliptical body, about the size of an 
almond, which slips or jumps away and is freely movable. The normal 
tube is difficult to palpate, giving the impression of a very soft rubber 
tube about the diameter of a lead pencil. The examiner can be sure 
only in very exceptional cases that the tube is felt. Muscular strands 
in the abdominal wall, or the round ligament, will often be mistaken 
for a normal tube. The right adnexa may be palpated by similar 
maneuvers on the opposite side. 

In the case of an adherent ovary the organ will be immovable and 
somewhat enlarged, and will feel as if it were stuck to the pelvic wall 
or floor. If the tube and the ovary are enlarged and adherent, they 
form an irregular, retort-shaped mass in which it is difficult to distin- 
guish one organ from the other. 

It is to be remembered that the position of the uterus will influence 
the position of the ovary. Thus, if the uterus is retroposed or in de- 
scensus, the ovary will be nearer the median line and lower; when the 
uterus is in the normal position, it is higher and more laterally placed. 
When the ovary is prolapsed, it may be felt by turning the palmar sur- 
face of the finger backward and palpating Douglas' cul-de-sac by 
pushing backward and outward. The ovary will be recognized as a 
smooth, elliptical body which slips away from the examining finger. 
A scybalous mass in the rectum gives a sensation to the finger very like 
a prolapsed ovary, but it may be excluded by noting that it pits on 
pressure or by making an examination per rectum. 

Bimanual rectal palpation, with the uterus drawn downward by means 
of a tenaculum, is a most valuable means of diagnosis in affections of 
the tubes and ovaries. The finger is inserted into the rectum and pushed 
backward and downward until it passes between the utero-sacral liga- 
ments; it is then turned upward upon the posterior surface of the uterus 
and to either side upon the posterior surface of the broad ligaments. 
45 



706 GYNECOLOGICAL DIAGNOSIS 

In the case of inflammatory affections of the ovaries and tubes irreg- 
ular masses will be felt back of the uterus on one or on both sides, 
displacing it forward. When an inflammatory affection involves the 
cellular tissue of the broad ligaments, the induration felt at the vaginal 
vault is very dense and board-like and extends all the way to the pelvic 
wall and fuses with it. 

Pelvic masses, without induration of the vaginal fornices or the 
bases of the broad ligaments, are usually uterine or ovarian in origin — 
uterine, if they are in connection or move with the uterus; ovarian, if 
they are distinctly separate from the uterus and independently movable. 
Induration of the broad ligaments or the vaginal fornices with immo- 
bility or partial fixation of the uterus, is suggestive of inflammatory 
disease involving the tubes and the pelvic peritoneum, possibly also of 
carcinoma with extension to the broad ligament, or of cellulitis. Pelvic 
enlargements rising slightly above the pelvic brim and decidedly lateral 
in position are apt to be inflammatory in type. Those which have a 
more or less median position and extend well into the abdominal cavity 
are usually newgrowths of the uterus or of the ovaries. 

Abdominal Examination.— Inspection.— The color of the skin, the 
presence of dilated veins, the contour of the abdomen, the linese 
albicantes, and the linea nigra are determined by inspection. The 
abdominal respiratory wave and the presence of any abdominal enlarge- 
ment are noted. The abdomen should be inspected from the side, from 
the feet, and from the head of the patient. In the presence of an ab- 
dominal tumor it should be observed whether the enlargement involves 
the entire abdomen or is confined to the lower part ; whether the enlarge- 
ment has a median or a lateral position, and whether its surface is even 
or irregular. 

Palpation. — Palpation verifies inspection as to the shape and the 
contour of the abdomen. It also confirms the situation as well as the 
regularity of surface of any abdominal enlargement which has been 
observed. Palpation also in addition discovers rigidity and tenderness 
and, combined with percussion, the physical sign of fluctuation. The 
tonicity of the abdominal wall may be determined by palpation. 
Diastasis of the recti muscles may be estimated by sinking the fingers 
between them v/hile the patient tries to raise herself into a sitting posi- 
tion. By palpation it can be ascertained whether an abdominal tumor 
is of pelvic origin. If the fingers can be dipped down between the tumor 
and the symphysis pubis, the tumor is probably not pelvic. In pelvic 
growths this maneuver meets with firm resistance. 

In making palpation the hands should be thoroughly warmed, the 
palmar surface should be pressed gently against the abdominal wall, 
making deeper pressure with the fingers as the patient's confidence is 
gained and the abdominal wall relaxes. In eliciting fluctuation it may 
be advantageous to have an assistant place the ulnar border of the hand 
in the median line of the abdomen or somewhere at least on the surface 
between the palpating and the percussing hand. In this way the spur- 
ious fluctuation due to an accumulation of fat in the abdominal parietes 
may be eliminated. 



THE VULVA 707 

Information concerning the consistency of an abdominal enlarge- 
ment, whether it is hard or soft, elastic or doughy, may also be gained 
by palpation. 

Percussion. — ^All tumors of the abdomen originating in the pelvis are 
dull on percussion. The area of dulness begins below at the pelvic 
brim and is most pronounced over the greater bulge or convexity of the 
tumor. Surrounding it above and at the sides there is resonance or 
tympany (coronal resonance). The percussion note changes with the 
the position of the patient when there is a free intraperitoneal collection 
of fluid. The percussion note over a tumor or over an encysted col- 
lection of fluid is little affected by position. 

Auscultation. — ^Auscultation is of service almost solely in distinguishing 
the fetal heart sounds and the placental bruit. 

THE VULVA. 

Malformation. — Malformations of the vulva include : 

Atresia of the urethra or the vagina. 

Persistent Cloaca. — ^The anus opens into the vestibule; there is no 
perineum. 

Hypospadias. — ^A congenital vesicovaginal fistula. 

Epispadias. — Usually accompanied by fissure of the clitoris, and some- 
times also of the symphysis and the entire anterior vesical wall. 

Infantile Vulva. — General absence of development of the labia majora 
and minora. 

Hermaphrodism. 

Imperforate hymen. 

Rigidity and thickness of the hymen. 

Inflammations. — -Vulvitis. — Causes. — Vulvitis is caused in the young 
by epidemic gonorrheal infection as seen in children's homes and 
hospitals, or by gonorrheal infection from the mother or the nurse, 
or through the medium of napkins, towels, etc. Thread-worms and 
uncleanliness may be factors in the vulvitis of children. In the adult, 
repeated gonorrheal infection from more or less constant bathing of the 
part with gonorrheal pus, irritating discharge from a vesical fistula, or 
an ulcerating carcinoma, diabetic urine, too frequent sexual inter- 
course, or masturbation may produce it. Streptococcus or diphtheritic 
infection of the vulva may occur in puerperal women. The rectal 
discharge in typhus fever and in dysentery may excite vulvitis. 

Symptoms. — ^Pain, which varies between a sense of discomfort or 
itching and a severe burning; difficulty in walking; leucorrhea. 

Examination. — The vulva is covered with a mucopurulent or purulent 
discharge. After this has been wiped or washed away, the vulvar mucosa 
is seen to be swollen, reddened, and edematous. In the gonorrheal 
vulvitis of children the vagina is usually coincidently affected. In 
adults, the urethra and the vulvovaginal glands, and often the cervix, 
are involved. The sebaceous glands of the labia majora and the labia 
minora may be inflamed, the lesions resembling those of acne (follicular 



708 GYNECOLOGICAL DIAGNOSIS 

vulvitis), and the vulvar mucosa between the follicles appearing normal, 
or at most but slightly reddened. To determine the type of infection 
smears and cultures should be made, in cases of vulvitis, from the dis- 
charge covering the surface of the vulva, the vulvovaginal glands, and 
Skene's tubules. In the adult, simultaneous infection of Skene's tubules, 
the vulvovaginal glands, and the cervix is almost always gonorrheal. 

Pruritus Vulvae. — Causes. — Pruritus vulvae is either a pure neurosis 
or a symptom produced by the irritation of substances circulating in 
the blood (bile, uric acid, urea, sugar, morphine, alcohol, or iodine); 
congestion or venous stasis of the vulva (heart disease, pregnancy, 
retroposition of the uterus, or uterine tumors); skin diseases (erythema, 
urticaria, herpes, eczema); carcinoma of the vulva (early symptom); 
irritating discharges (hyperidrosis, diabetic urine, ammoniacal urine, 
leucorrhea from gonorrheal infection of the cervix or the uterus, carci- 
noma or decomposing fibroid tumor); rectal discharge (purulent and 
catarrhal inflammation of the rectum); parasites, animal (pediculi, 
oxyuris vermicularis) and vegetable (leptothrix, leptomitus, oidium 
albicans); heat (pruritus estivalis) and cold (pruritus hiemalis), or by 
masturbation. 

Symptoms.— Intense itching of the vulva, worse at night and under 
the influence of warmth and exercise; worse also during pregnancy and 
during the menstrual periods. Because of an uncontrollable desire to 
scratch, the patient avoids society and becomes depressed and nervous. 
Relief may be sought in drugs. 

Examination. — The vulvar surface usually shows one of the local 
conditions noted above. The presence of scratch marks is noted upon 
the skin. In old cases there is considerable thickening of the vulvar skin 
which becomes leathery and has a dead white surface broken here and 
there by the excoriations made by the patient's finger nails. Urinalysis 
may discover sugar, bile, or an excess of uric acid. In every case of 
pruritus it is very important to determine the underlying lesion. In the 
few instances where none of the causes already mentioned are found 
the disease may be regarded as a pure neurosis. 

Kraurosis Vulvae. — ^A very rare condition characterized by an atrophy 
and a shrinkage of the vulvar parts. 

Adhesions of the prepuce to the glans clitoris is a common condition 
which produces irritation only when an accumulation of smegma occurs 
behind them. 

Elephantiasis of the Vulva. — Cause. — Syphilis is the usual cause in 
this country. Symptoms are due to mechanical irritation, and there is 
inconvenience in walking or in sexual intercourse. 

Examination. — ^There is hypertrophy of the labia majora and minora; 
the parts are indurated and sometimes edematous. Excoriations or 
warty outgrowths may appear upon the surface. 

Venereal Sores. — ^The venereal lesions in the female differ slightly 
from those in the male. Neither the chancre nor the chancroid is so 
constant in form. The appearance of each is modified by the personal 
cleanliness of the woman, by her habits, by bruising of the vulvar parts 



THE VULVA 709 

at the time when infection occurs, and by the chemical and mechanical 
irritation of strong disinfecting solutions which are sometimes used 
before a physician is consulted. For this reason, edema and induration 
of the labia majora are not infrequent in association with venereal lesions. 

Chancre. — For a description of the chancre see p. 643. It is not so 
often observed in the female. The lesion occurs upon the vulva or 
the cervix and commonly takes the form of the indurated papule. It 
is said to be multiple sometimes. The diagnosis is confirmed by 
indentification of the treponema (spirocheta) pallidum in suitably stained 
preparations. 

Chancroid. — Chancroid in the female resembles the same sore in the 
male (see p. 645). 

Herpes Vulvse. — Herpes vulvae resembles herpes preputialis (see p. 643). 

Secondary syphilitic lesions of the vulva occur quite frequently. A 
papular syphilide developing upon the vulva often has an abraded and 
secreting surface, and is partly or completely covered by a gray, adher- 
ent, offensive pseudomembrane. This is a mucous patch. Sometimes the 
moist papule takes on a distinct papillary overgrowth (condyloma). 
Condylomata appear as raised, flat, raw surfaces; the cellular infiltra- 
tion is so abundant that the papillary nature of the growth is but imper- 
fectly marked and may be observed only after careful inspection. When 
the mucous patch preceding the condyloma has developed from a large 
papular syphilide, the elevated surface varies in size from a shirt button 
to a penny. 

Tertiary syphilitic lesions of the vulva are rare. Gumma of the labia 
majora is the usual lesion; it shows a tendency to break down and 
suppurate. 

Venereal Warts. — Causes. — ^Venereal warts result from the irritation 
of uncleanliness or from the irritation of gonorrheal pus. They are 
also associated at times with secondary syphilitic lesions. 

Symptoms. — ^Their symptoms vary between actual discomfort and 
pain. Usually they simply interfere mechanically with walking or inter- 
course. When inflamed, they are painful. They sometimes have a 
thin and highly irritating discharge. 

Examination. — ^Venereal warts appear as papillary excrescences, either 
in a single discrete group or in a coalescent cauliflower-like mass. They 
may occur on the vulva, mons veneris, perineum, or anus. They are 
also occasionally found on the vagina and upon the cervix. They 
usually have a purplish red color; the surface is moist and divided into 
small projections which have pointed ends (condyloma acuminatum). 

Enlargements and Tumors of the Vulva. — Varicose Veins of the 
Vulva. — Causes. — ^Pregnancy, pelvic exudates, pelvic tumors, retro- 
position of the uterus with adhesions, straining at stool, prolonged 
standing, and heavy work are causes. They are usually found in the 
labia majora; the other parts and the vagina may be involved. 

Symptoms. — Itching and burning, or a sense of discomfort or of weight. 

Examination. — An elongated, knotty, bluish enlargement is found 
made up of dilated and tortuous veins. Upon palpation they resemble 



710 



GYNECOLOGICAL DIAGNOSIS 



a bundle of earth-worms. The condition varies from a slight distention 
of the vulvar veins to a tumor as large as the fetal head. 

Hematoma of the vulva is caused by the subcutaneous rupture of vari- 
cose veins during pregnancy or labor, or as the result of a fall or of a 
blow. 

Symptoms. — Sudden pain in the affected part, with rectal or vesical 
tenesmus. Later there is also a feeling of fulness, and, if suppuration 
occurs, the signs of abscess. 

Examination shows a purplish globular tumor which may be as large 
as the fetal head. It is tense and elastic at first, but later doughy. 



Fig. 437 



Fig. 438 




Early carcinoma of the vulva, confined to the 
clitoris. 



Early adenocarcinoma of the vulva, limited 
to the left lesser labimn. (Hurdon). 



Carcinoma of the Vulva. — Causes. — ^Primary carcinoma is usually of 
the squamous type (epithelioma), and may be preceded by psoriasis, 
papillomata, or some trauma. There may be no preceding lesion. 
Secondary carcinoma results from carcinoma higher in the genital tract, 
and may be of the cylinder-cell variety (adenocarcinoma). The growth 
begins in the sulcus between the labium ma jus and the nympha, or upon 
the clitoris or in the urethra. It occurs in subjects between the ages of 
forty and sixty years, rarely in the young (one case aged twenty- three). 

Symptoms. — Pruritus is the most common early symptom, but is not 
characteristic. There may be no early subjective symptoms. Later, 
when ulceration has occurred, pain is more or less constant and severe. 
The inguinal glands on the affected side become enlarged. There is a 



THE VULVA 



711 

General ill-health and 



foul-smelling discharge and slight hemorrhage, 
cachexia supervene. 

Examination. — The affection first appears as a small, indurated, 
elevated nodule. Later, ulceration occurs. The edge of the ulcer is 
elevated, hard, and bluish red. The surface is granular and is covered 
by a semi-opaque putrid secretion. Little ''maggot-like" bodies can 
often be pressed out of the floor of the ulcer. They are epithelial 
pearls, or nests, and are highly diagnostic of squamous carcinoma or 
epithelioma. The labium surrounding the carcinomatous ulcer becomes 



Fig. 439 




Epithelioma of the vulva (labium majus). Indurated fungoid ulcer. Slight trauma causes 
free bloody oozing. Enlarged right inguinal lymphatic glands. Diagnosis made by microscope. 
(Carnett). 



thickened and indurated. The opposing surfaces of the vulva may 
develop a carcinomatous growth from contact. 

Differential Diagnosis. — It is important to diagnose the condition in its 
earliest stage. To this end any suspected lesion should be immediately 
excised and submitted to microscopic examination. 

Lupus appears at a younger age. The affection progresses very slowly 
and there is little pain. Instead of single hard nodules, there are mul- 
tiple soft nodules. The discharge is not putrid. The ulceration tends 
to undergo cicatrization. Healthy skin is frequently found between 
neighboring lesions. The inguinal glands are not involved, as a rule. 



712 GYNECOLOGICAL DIAGNOSIS 

Chancre. — There is a history of infection and a period of incubation. 
The sore develops rapidly, is not painful, and does not spread; there 
is a thin, scanty, sanious discharge. The inguinal glands enlarge early 
and constitutional symptoms appear. 

Chancroids. — There is a history of contagion and a short period of 
incubation. The lesions are multiple and inflammatory; they spread 
rapidly and are auto-inoculable. Inguinal enlargement is early and per- 
haps unilateral. 

Venereal Warts. — ^Unless the diagnosis is plain, the growths should be 
excised and examined microscopically. It should be remembered that 
papillomata may become cancerous. 

Sarcoma of the vulva usually affects the labia majora. It begins as a 
hard, round nodule, brown or black in color. It grows rapidly; ulcera- 
tion occurs late. The inguinal glands are involved late. The disease 
is usually fatal. Death occurs from metastasis through the veins. 

Lupus of the vulva is rare. The lesion is produced by the tubercle 
bacillus, and consists early of nodules varying in size from a pinhead to 
a bean, embedded rather deeply in the skin; the nodules have a reddish, 
brownish, or a yellowish red color. Later, these become larger and 
undergo cheesy or colloid degeneration. Ulceration finally takes 
place. The ulcers are soft and usually superficial; they may be deep, 
causing a fistulous communication between the vagina and the sur- 
rounding parts. The ulcerations have bright red granulations, they 
bleed easily, and are covered with pus which does not have a bad odor. 
Cicatrization occurs irregularly and may produce stricture or stenosis 
of the urethra, vagina, or rectum. There is a general increase of con- 
nective tissue in the affected parts, sometimes resembling elephantiasis. 
There is little pain and the growth is very slow. 

Fibromyoma of the vulva affects the labia majora principally and has 
the same structural features as fibromyoma elsewhere. The symptoms 
are the result of mechanical interference. The condition is very rare. 

Lipoma of the vulva affects the labia majora or the mons veneris and 
resembles lipomatous tumors found in other parts. 



THE VULVOVAGINAL GLANDS. 

Inflammation of the ducts of the vulvovaginal glands is usually the 
result of gonorrhea. Other infections extending from the surface may 
cause it. In gonorrheal inflammation of the duct the orifice is sur- 
rounded by a red, slightly elevated spot, known as the gonorrheal macule. 
Pressure over the course of the duct will express a drop of pus. Inflam- 
mation of the ducts of the vulvovaginal glands may lead to a retention 
cyst or to an extension of the infection to the gland substance with the 
production of an abscess. 

Abscess of the vulvovaginal gland is evidenced by severe pain and 
marked swelling and edema of the surrounding parts. The swelling 
may extend even to the anus. Fluctuation appears first upon the inner 



THE VAGINA 713 

surface of the labium, and, if the pus is not evacuated by an incision, it 
finally finds exit through several fistulous openings below the orifice of 
the duct. These may keep on discharging indefinitely. 

Cyst of the vulvovaginal glands results either from an occlusion of the 
duct by an inflammatory process or from thickening of the glandular 
secretion. The symptoms produced by vulvovaginal cysts are usually 
the result of mechanical interference with sitting, walking, or sexual 
congress. 

Examination. — Vulvovaginal cysts vary in size from that of a walnut 
to a tumor as large as a child^s head. When as large as an egg or over, 
the mucosa to the inner side of the labium, overlying the surface of the 
cyst, is considerably thinned. The cyst contents are clear and colorless, 
or yellow, or a turbid, chocolate color from admixture with blood. 
Vulvovaginal cysts must be distinguished from inguinal hernia, hydrocele 
of the canal of Nuck, and cysts of old hernial sacs. In them the 
enlargement is more to the upper and outer part of the labium majus, 
and is connected with the external inguinal ring. 



THE VAGINA. 

Malformations of the Vagina. — Vaginal Septa. — ^Vaginal septa usually 
extend upward from the vulva and divide the vagina into two passages, 
seldom of equal size. Both of the divisions may communicate with the 
uterus or one of them may end blindly. Various malformations of the 
uterus may be associated with vaginal septa. 

Hematocolpos. — The hymen is imperforate and the vagina is dis- 
tended with an accumulation of the menstrual fluid. The condition 
does not arise until after the onset of puberty. The menstrual molimina 
develop, but the flow does not appear. 

Atresia of the vagina may be the result of adhesive inflammations 
occurring before birth (congenital atresia) or during early life. 

Complete absence of the vagina is a very rare condition and is usually 
associated with an absence or a defective development of the uterus, 
tubes, and ovaries. 

Inflammations. — Vaginitis. — ^Vaginitis is usually subacute or chronic, 
except in children. It depends in the adult upon repeated infection 
plus a mechanical irritation or injury, or upon some general condi- 
tion which lowers the vitality of the vaginal mucosa. Predisposing 
causes are venous stasis, the hyperemia incident to pregnancy, small 
abrasions of the mucosa, and the irritation of foreign bodies. An irri- 
tating gonorrheal discharge from the cervix is the most frequent cause. 
Vaginitis occurs in connection with vesicovaginal fistula and sometimes 
also with the exanthemata. Dysenteric discharges, caustic solutions, 
the streptococcus and the diphtheria bacillus may produce it. 

Examination. — In acute vaginitis the vaginal walls are red, swollen, hot, 
and very tender. They are covered with a mucopurulent or a purulent 
discharge. The entire extent of the vagina is not involved usually except 



714 GYNECOLOGICAL DIAGNOSIS 

in children. The vulva is bathed in the discharge, which becomes 
highly offensive. 

In subacute or in chronic vaginitis the vaginal surface shows 
numerous small red spots; these are caused by inflammatory infiltra- 
tion of the papillae in the vaginal mucosa. The overlying epithelium 
subsequently desquamates and small eroded areas are formed. In 
old persons such areas, when they are apposed, may adhere. The 
vaginal walls are covered with a thinner and a less purulent discharge 
than in the acute form. In old chronic cases the lesion may be con- 
fined to eroded patches, in the vaginal vault. In children the local 
examination should be confined to an inspection of the vaginal orifice 
or to the introduction of a small Kelly cystoscope into the vagina. The 
examination of the vagina in the adult is preferably made by means of 
a Sims speculum, with the patient in the Sims or the knee-chest position. 

Tumors. — Vaginal Cysts. — Vaginal cysts are the most frequent of the 
vaginal tumors, but, even so, they are rare. They result from the dis- 
tention of aberrant vaginal glands, inclusion of epithelium following 
operations, hematoma, dilatation of a lymph vessel, and the echino- 
coccus. Dermoid cysts are found rarely. Cysts may also arise from 
rests of the Wolffian duct in the upper part of the vaginal vault. Such 
cysts are often multiple and occur in a row. Vaginal cysts are hemi- 
spherical or ovoid and project more or less into the vagina. Rarely 
they may be pedunculated. The overlying mucosa is thinned out. 
The contents of a cyst may be clear, thin, and watery, or gluey and 
opalescent, or chocolate colored. 

The sympicms are nil when the tumor is small. When large, there 
is interference with urination and defecation. The tumor may form 
an obstruction to intercourse or to labor. There may be a fetid leucor- 
rhea if the passage of the menstrual fluid is obstructed and an accumu- 
lation occurs above the tumor. The condition must be distinguished 
from cystocele, rectocele, and suburethral abscess. 

Fibromyoma of the vagina is an infrequent form of vaginal tumor. 
It has the same peculiarities as fibromyoma elsewhere. 

Sarcoma of the vagina is very rare. In adults it forms a diffuse growth 
which may be situated in any part of the canal. In young children it is 
polypoid or grape-like in form and springs from the anterior vaginal wall. 

Carcinoma of the Vagina. — ^Primary cancer is very rare. Cancer of 
the vagina is usually secondary to a growth higher in the genital tract. 

Rectovaginal fistula in the upper part of the vagina is usually pro- 
duced by carcinoma; in the lower part by ulcerative processes of a 
tuberculous or a syphilitic nature or by the failure of operation for a 
complete tear. 

THE PELVIC FLOOR. 

Recent tears of the perineum belong to the subject of obstetrics and 
will not be discussed here. 

Relaxation of the pelvic floor is the result of an injury to the levator 
ani and other muscles incurred during childbirth. The symptoms of a 



THE CERVIX 715 

relaxed pelvic floor are a feeling of loss of support, dragging and bearing- 
down sensations in the lower abdomen, and backache. All of the 
symptoms are increased by exertion and are relieved by the recumbent 
position. 

Examination should be made with the patient in the dorsal position. 
Scars may be seen in one or both vaginal sulci, indicating the position 
of previous tears. The perineal body may appear cleft in the median 
line, or to one side. If the lacerations have been subcutaneous, no 
evidence of a previous tear of the mucous membranes will be observed. 
Upon further inspection, it will be found that the anal cleft is shallow, 
the anus is prominent, the distance from the external urinary meatus 
to the anus is increased, the perineal body is low, the vaginal orifice 
is gaping, the anterior and the posterior walls are either not in contact 
or they show the presence of cystocele and rectocele. If the woman 
is directed to ''bear down," the anterior and the posterior vaginal 
walls protrude. If the vulva is pricked, the woman draws herself 
away; no reflex muscular action closing the vagina and drawing up 
the anus is observed. A relaxed pelvic floor may be complicated by 
cystocele and rectocele, laceration of the cervix, and descensus, retro- 
position, or prolapsus of the uterus. 

Rectocele. — A rectocele is a protrusion of the rectovaginal septum in 
the direction of the vaginal outlet. The patient may be unaware of its 
presence, or she may feel the protrusion at stool and imagine she has 
falling of the womb. She may also experience difficulty in defecation, 
and may only partially succeed until the rectocele is pushed backward 
and upward with the finger. The condition may be diagnosticated by 
introducing a finger into the rectum and directing it upward, when it 
will enter the most prominent part of the rectocele. 

Cystocele. — A cystocele is a protrusion of the vesicovaginal septum in 
the direction of the vaginal outlet. It causes difficulty in thorough 
evacuation of the bladder; there is usually, in bad cases, a certain 
amount of residual urine which is apt to decompose and produce 
cystitis. The tip of a sound introduced into the bladder and turned 
downward will enter the most prominent part of the cystocele. 

THE CERVIX. 

Malformations. — Double Cervix. — Two completely formed cervices 
may occur with a double uterus and a double vagina. 

Septate cervix may exist alone or in connection with a septate uterus 
or with a uterus bicornis. 

Infantile Cervix. — ^The cervix is long and conical with a very small 
external os; this condition is apt to be associated with a poorly 
developed vaginal vault and a sharply anteflexed cervix. 

Pathological Anteflexion of the Cervix. — ^While the cervix is nor- 
mally anteflexed upon the uterus, sometimes the condition is exaggerated, 
and it may be associated also with a conical, infantile cervix and a 
stenosed cervical canal. Under these circumstances the condition 



716 GYNECOLOGICAL DIAGNOSIS 

produces symptoms and the anteflexion is spoken of as pathological. 
The symptoms are dysmenorrhea, in which the pain precedes and sub- 
sides with the establishment of the flow, and, in married women, sterility. 
The diagnosis is made from the typical dysmenorrhea, and the physical 
findings as elicited by inspection of the cervix, bimanual palpation, and 
the introduction of a uterine sound. 

Laceration of the Cervix and its Complications. — Cervical Lacera- 
tions. — Lacerations of the cervix result from childbirth. They may 
be unilateral, bilateral, anterior, posterior, or stellate. A lateral lacera- 
tion is usually worse on the left side. 

Symptoms. — A cervical laceration does not, as a rule, give rise to 
symptoms unless the laceration is complicated by eversion, cystic 
degeneration, or hypertrophy of the cervical lips, endometritis, or sub- 
involution of the uterus. In the case of an extensive tear into the para- 
cervical connective tissue, pelvic pain may be referred to the scar. 

The diagnosis of a cervical laceration is made by inspection and by 
simple digital palpation. 

Eversion of the cervical lips is the result of bilateral laceration of the 
cervix. The bright red cervical mucosa is exposed to view. Because of 
mechanical irritation, the glands of the exposed mucosa secrete an excess 
of cervical mucus. The most prominent symptom is a profuse, thick, 
ropy discharge. Sterility may ensue because of the leucorrhea and the 
displacement of the external os. When the cervix is actually inflamed, 
pelvic pain may be present, the result of a complicating para-uterine 
lymphangitis or lymphadenitis. Other symptoms may be present if 
endometritis or subinvolution of the uterus exist. 

Examination. — The anteroposterior diameter of the cervix is increased. 
The scars of the lacerations may be felt as well as the slightly irregular 
velvety surface of the cervical mucosa; the sensation imparted to the finger 
by the latter is quite different from the smooth, firm surface of the normal 
cervix. Inspection should be made with the patient in the Sims or in 
the knee-chest position. The cervix appears bright red and granular; 
the folds of the cervical mucosa and the lacerations can be plainly seen. 
There is an abundant secretion of mucus. By catching each cervical 
lip with a tenaculum at the border between the exposed cervical mucosa 
and the vaginal surface of the cervix and approximating them, the 
normal relation of the cervical lips will be restored, the everted mucosa 
will disappear, and the cervix will approach its normal appearance. 

Cystic Degeneration of the Cervix. — Nabothian cysts are produced by an 
occlusion of the ducts of the cervical glands. This results from inflam- 
matory processes following laceration, eversion, or infection of the cervix. 
The small cysts, varying in size from a pinhead to a large pea or bean, 
extend peripherally and appear on the vaginal surface of the cervix. 
The entire cervix may be riddled with them, the connective tissue of 
the cervix undergoing considerable hypertrophy. 

Symptoms. — There are no distinctive symptoms. The condition is 
usually combined with the causal factors already mentioned. Upon 
examination, the cervix is found to be hard and the small cysts feel 



THE CERVIX 717 

like shot embedded in the cervical tissue. Puncture of a cyst leads to 
the escape of a thick, glairy mucus. 

Inflammation of the Cervix.^ — Catarrh of the cervix is caused by 
gonorrhea and by infection from unclean instruments. It may be 
secondary also to laceration and eversion of the cervix, to the use of 
cold douches, to imperfect involution of the cervix after labor, mis- 
carriage or abortion, or to malposition of the uterus. The only symp- 
tom referable directly to the catarrh itself is a thick, tenacious discharge 
which is mucous or mucopurulent and may prevent conception. Other 
symptoms depend upon complicating or causative lesions, and are: 
sensation of a dull, heavy weight and dragging in the pelvis, burning 
in the vagina, backache, vertical headache, menorrhagia, etc. 

Examination. — Inspection shows the cervix slightly enlarged and con- 
gested. The external os is open and filled with a thick, tenacious secre- 
tion. Upon wiping this away the mucosa of the cervical canal is seen 
to be prolapsed slightly beyond the external os, giving an appearance 
resembling but at once distinguishable from eversion. Surrounding the 
prolapsed mucosa there may be an area of true superficial erosion of 
the mucosa of the vaginal cervix. Nabothian cysts may be present, 
also some increase of the connective tissue and hypertrophy. 

Newgrowths. — Cervical Polyp. — A cervical polyp is produced by 
an outgrowth from the cervical mucous membrane which finally 
becomes pedunculated. Polyps vary in shape and in size; they may 
be elongated or pyriform, depending upon whether they lie within the 
cervical canal or project from the external os; they vary in size from a 
pea to a walnut. 

The symptoms are leucorrhea, from an overproduction of cervical 
mucus, menorrhagia, and dysmenorrhea. Metrorrhagia may occur 
after sexual intercourse or some unusual trauma. Inspection shows a 
pedunculated, spongy, or Velvety tumor lying in or projecting from the 
cervical canal. The external os is patulous; the tumor is usually bright 
red in color, and in external cases its pedicle can be detected passing 
into the cervical canal. Adenomatous polyps are to be distinguished 
from small pedunculated fibroid tumors of the cervix. 

Pedunculated fibroid tumors of the cervix feel smooth and hard; they 
are usually of considerably greater size than polyps and have a pinkish 
white color, unless necrotic changes have occurred, when they appear 
gangrenous and there is a fetid discharge. Pedunculated fibromyomata 
of the cervix also cause greater menorrhagia and more often metrorrhagia 
than do polyps. 

Venereal Warts of the Cervix. — Papillary, or warty, outgrowths of the 
cervical mucosa are rare. They are not as indurated and do not bleed 
as readily on palpation as carcinoma. In all cases, however, as the 
condition is suggestive of malignancy, the entire growth should be 
excised at once and the diagnosis made microscopically. 

Cancer of the Cervix. — Cancer of the cervix occurs usually between the 
ages of thirty and fifty years; most frequently at about the time of the 
menopause. It may occur in early adult life. Almost invariably it 



718 



GYNECOLOGICAL DIAGNOSIS 



affects the childbearing woman and especially those who have had 
repeated pregnancies. A badly lacerated cervix predisposes to cancer. 
The disease begins either upon the vaginal aspect of the cervix or within 
the cervical canal. 

Symptoms. — There are no symptoms pathognomonic of cancer. The 
earliest symptom is usually hemorrhage between the regular menstrual 
periods — ^bleeding from the uterus after exertion, sexual intercourse, or 
straining at stool. Hemorrhage from a cancer which develops after 
the menopause has often been taken for a return of the menstrual 
flow. The first symptoms may' be an inoffensive leucorrheal dis- 
charge. Late in the disease, when the carcinoma begins to undergo 
disintegration and is spreading widely, there are frequent and ex- 
hausting hemorrhages, profuse fetid discharge, pain, and cachexia. 
The discharge at this time is purulent, bloody, and mixed with pieces 
and shreds of putrefying cancerous tissue. The pain is either dull 
and gnawing or sharp and lancinating. It is referred to the sacrum, 
crest of the ilium, ovarian region, or along the sciatic nerve. If the 
cervical canal is blocked and the uterus becomes distended with blood, 

pus, or gas (hemato-, 
Fig- 440 PJO-j ^^ physomctra), 

the patient may com- 
plain of colicky pain 
or intense bearing- 
down sensations. The 
anemia and the 
cachexia of cancer are 
due to the loss of 
blood and the absorp- 
tion of toxins from 
necrotic cancerous 
tissue. 

Examination. — Un- 
less the diagnosis is 
made early, the case is 
hopeless. Carcinoma 
beginning upon the 
vaginal aspect of the 
cervix is easier to diag- 
nosticate early than carcinoma which originates in the cervical canal. 
In the early stage of either form the cervix feels thickened and hard, 
and hemorrhage is apt to follow palpation. Upon exposure of the cervix 
in the external form, numerous large and small bosses are seen on the 
mucosa which have a glazed, bluish white appearance, as though the 
tissue were very tense and ready to burst. On careful study at several 
points masses of teat-like or branching papillae are seen which are 
very friable and bleed readily. Often the papillae are held together 
in masses by ropy mucus, and may be easily overlooked (Cullen). 
Later they grow rapidly and form cauliflower-like projections. 




Early carcinoma of the anterior cervical lip. 



THE CERVIX 



719 



Carcinoma may appear early also as an ulceration. True ulceration 
of the cervix, that is, actual loss of tissue, except it be very superficial, 
is almost always cancerous. The cancerous ulcer bleeds readily, is 
indurated, and has friable edges, ^^^len carcinoma begins in the 
cervical canal low down, the os is dilated and the growth may be seen 
through the cervical canal. When it starts high up in the canal, the 
growth may be far advanced before it becomes visible. The only 
evidence in these cases is from the hard nodular state of the cervix 
and the tendency to hemorrhage after palpation. In advanced cases 
there are cauliflow^er masses projecting from the cervix or a deep ulcer 
of the cervix. In the final stage of any form of cancer, the cervix is 
destroyed and the cancerous excavation extends to the surrounding 
tissues and organs. 

As already stated, a diagnosis of carcinoma of the cervix, except in 
the early stages, is useless, so far as a cure of the disease is concernedo 



Fig. 44 j 




Same case as Fig. 440, a part of the cancerous area magnified, showing the finger-like projections. 



Early carcinoma of the cervix must be distinguished from an eversion 
of the cervical lips, prolapse of the cervical mucosa and cervical catarrh, 
cystic degeneration of the cervix, venereal warts, chancre, tuberculosis, 
small interstitial myomata, sloughing submucous myomata, and cervical 
polyps. In any suspicious case, when the diagnosis is not certain , 
curettage of the uterus and amputation of the cervix, or trachelor- 
rhaphy should be performed at once and the excised tissue and the 
curettings should be submitted to expert microscopic examination. 

Sarcoma of the Cervix. — Sarcoma of the cervix is much less frequent 
than carcinoma. There are certain cases of sarcoma (grape-like) in 
which the tumor consists of outgrowths which appear cystic and 
resemble the hydatidiform mole. These growths usually occur in persons 



720 GYNECOLOGICAL DIAGNOSIS 

under the age of twenty and are rather characteristic in appearance. 
Other varieties of sarcoma of the cervix are difficult to differentiate 
from cancer except by a microscopic examination. 

THE UTERUS. 

Malformations. — Infantile uterus varies from a uterus smaller than 
normal to one represented simply by a fibrous cord. 

Double Uterus. — Two complete uteri lying side by side- — each has one 
round ligament, one tube, and one ovary. 

Bicornate Uterus. — The union of the Miillerian ducts has occurred 
at a lower point than normal, giving the uterus a "Y" shape. 

Uterus Septus.— The uterus has a normal appearance externally, but 
the endometrial cavity is divided into two by a median septum; each 
of these cavities communicates with the tube on its corresponding side. 

In either the bicornate or the septate uterus pregnancy may occur 
on one side; or one horn or one division may be imperforate, resulting 
in hematometra. 

Uterine Displacements. — Retroposition of the uterus is usually 
caused by childbirth, being preceded or accompanied by relaxation of, 
the pelvic floor, abdominal wall, and the uterine ligaments, and by 
subinvolution of the uterus. Constant coughing or straining (hard 
work) predispose to retroposition. Pelvic inflammatory disease may 
complicate retroposition of the uterus. In such a case the uterus is 
bound down by adhesions. Falls, violent contortion of the body, or a 
sudden effort to lift, may cause retroposition in the young. Retroposition 
may also be congenital. It always precedes, to a certain degree, 
descensus or prolapse. 

Retroflexion is a bending of the fundus backward on the cervix, and 
is commonly associated with retroposition. The symptoms include 
vertical or occipital headache, sacral backache, and a feeling of weight 
and dragging in the pelvis which extends into the thighs. Irritability 
of the bladder and constipation frequently arise. The symptoms are 
relieved by the recumbent posture. Dysmenorrhea, menorrhagia, and 
leucorrhea may be present if there are congestion and chronic inflam- 
mation of the endometrium. 

Diagnosis. — The body of the uterus is not felt in its normal anteposi- 
tion; the cervix is not directed toward the coccyx, as in the normal 
position, but lies in the axis of the vagina. The body of the uterus is 
felt through the posterior vaginal fornix; it is directed backward toward 
the sacrum. There is an angle of retroflexion between the cervix and 
the body. By sinking the abdominal hand deeply into the pelvis, below 
the promontory of the sacrum, the fundus can be palpated between the 
two hands. 

Descensus and Prolapsus Uteri.— Descensus is the first stage of prolapsus; 
when the uterus falls slightly below its normal level it is said to be in 
descensus. Retroversion is nearly always present before descensus or 
prolapsus occurs. There are various degrees of prolapsus best de- 



THE UTERUS 721 

scribed by the position of the cervix: (1) What may be called descensus, 
when the cervix has descended into the vagina to an appreciable degree; 
(2) when the cervix presents at the vulvar outlet; (3) when the entire 
uterus is outside the body, spoken of also as procidentia. 

Exceptionally prolapse takes place as the result of a violent muscular 
effort. Usually it is the final result of relaxation of the pelvic floor, 
abdominal walls, and uterine ligaments. As the organ descends into the 
vagina, the latter is inverted ; the bladder wall and the rectal wall may 
or may not come down with the vagina. In case the prolapse is mainly 
caused by traction on the cervix from a relaxed pelvic floor, and the 
fundus of the uterus is held in fair position by its ligaments and the 
retentive power of the abdomen, there occurs an elongation and a thin- 
ning of the supravaginal cervix. The symptoms are those of a relaxed 
pelvic floor, depending in severity upon the degree of the prolapsus. 
Bladder and rectal symptoms as described under cystocele and rectocele 
are present. In complete prolapsus there may be considerable interfer- 
ence with walking; pressure ulcers of the vaginal mucosa may develop, 
accompanied by a foul-smelling discharge. The symptoms vary in 
intensity in different individuals, and sometimes bear no relation to the 
extent of the displacement. 

Examination. — Procidentia is readily recognized. The pear-shaped 
tumor projecting from the vulva with the cervical canal at its apex can 
hardly be mistaken for anything else. Inversion of the uterus and a 
pedunculated fibroid may bear some resemblance. Any doubt is dis- 
pelled by putting the patient in the knee-chest position, when in the case 
of prolapsus the tumor is readily reduced. In minor degrees the uterus 
may go back more or less completely when the woman is in the dorsal 
position, even though it projects from the vagina when she is erect. The 
degree of descensus can be determined by having the patient "bear 
down" or by pulling on the cervix with a tenaculum. When there is 
supravaginal elongation of the cervix the fundus is not correspondingly 
prolapsed and the endometrial cavity is lengthened. 

Inflammations. — Acute endometritis is due to gonorrhea or to septic 
infection. The symptoms in the gonorrheal form begin during or after 
a menstrual period; if during a period, the flow suddenly stops; if after 
a period, there is a diminution in the cervical leucorrhea, the attack 
is marked by pain in the back and lower abdomen, vesical irritability, 
and tenesmus, constipation, headache, rise of temperature (101°) and 
pulse. Within a few days a profuse purulent discharge appears. 

Examination of the excretion from the vulvovaginal glands or from 
Skene's tubules will often reveal the gonococcus. Gonorrheal endo- 
metritis readily passes into gonorrheal salpingitis, and it is usually hard 
to say where one ends and the other begins. 

In the septic form the symptoms follow the introduction of septic 
material into the endometrial cavity, either by an instrument or by the 
finger. The uterus may be puerperal or not. If puerperal the condition 
is a form of puerperal sepsis and more serious than when the uterus has 
not been pregnant. The symptoms in general resemble those of acute 
46 



722 GYNECOLOGICAL DIAGNOSIS 

gonorrheal endometritis, but are more severe; the temperature and the 
pulse are higher; chills or chilly sensations are more frequent, and the 
evidences of a toxemia are more likely to appear. The local symptoms 
depend upon whether the uterus is puerperal and upon the nature of the 
infecting organism. If the infection is of a virulent type, there may be 
little local reaction; in this case the disease rapidly advances beyond the 
endometrium, toxemia or bacteremia develop, and the patient dies with 
few structural changes in the pelvis. With less dangerous infection in a 
puerperal case there is at first a diminution, and later an increase in the 
lochial discharge. In case placental or decidual tissue has been retained 
within the uterus, the lochia has a foul odor. In non-puerperal cases, 
there is a puriform discharge streaked with blood. 

Examination. — Bimanual palpation of the uterus reveals enlargement, 
tenderness, and perhaps edema. The os is usually patulous. It is 
diflScult to differentiate acute endometritis from acute metritis or mild 
inflammatory lesions of the appendages. 

Chronic endometritis usually occurs in association with some other 
pelvic lesion, such as retroposition of the uterus, fibroid tumor, or 
inflammatory disease of the appendages. It may exist alone. Leucor- 
rhea is the most common symptom. The discharge is thin unless the 
cervix is coincidently the seat of catarrh; dysmenorrhea, profuse men- 
struation, and in exceptional cases metrorrhagia may be caused by 
chronic endometritis. As an independent lesion it has little significance. 

Acute metritis is customarily associated with endometritis of the septic 
type and other inflammatory pelvic lesions. Its symptoms vary between 
those of septic endometritis and pelvic peritonitis, from which it is 
difficult and unimportant to differentiate. 

Chronic metritis is the residuum of an acute infection or the result of 
long-continued subinvolution of the uterus. It is frequently associated 
with chronic endometritis and displacement. The symptoms are back- 
ache and dragging sensations in the lower abdomen, profuse menstrua- 
tion, and an irritating leucorrhea. The uterus is symmetrically enlarged. 
The diagnosis is made by excluding fibroid tumor and cancer. 

Newgrowths. — Cancer of the body of the uterus occurs somewhat 
later in life than cancer of the cervix; usually between the ages of fifty 
and sixty. It is often found in single or nulliparous women. Fibroid 
tumor seems to predispose to carcinoma. 

Symptoms. — ^The earliest symptom usually is metrorrhagia. Menor- 
rhagia may be the first indication of the disease. Sometimes more or 
less periodical hemorrhage occurs after the menopause and is taken by 
the patient for a return of menstruation. Metrorrhagia may follow 
coitus, straining at stool, or any pronounced exertion. The onset of 
leucorrhea or the exaggeration of a chronic discharge may be the first 
symptom. The discharge is commonly serous; it may have a disagree- 
able odor and cause irritation of the external genitalia; it may be streaked 
with blood. There is little or no pain in the earlier stages. After the 
disease is advanced, hemorrhage increases in amount and is more or 
less constant. There is a profuse, purulent, dirty brown discharge, 



THE UTERUS 



723 



which has a putrid odor, and contains disintegrated blood clots and 
shreds of necrotic cancer tissue. Pain is constant or intermittent, being 
described as shooting, burning, or colicky. It is felt in the lower abdo- 
men, lumbosacral region, thighs, and along the crest of the ilium. 

Examination in the Early Stage. — ^The uterus is normal in size or 
slightly and symmetrically enlarged. It may be a little softer than nor- 
mal; the cervical canal is patulous, or easily dilatable. Hemorrhage 
may follow bimanual palpation. Such symptoms in a woman between 
forty-five and sixty years should be considered indicative of malignant 
disease until proved otherwise. In the late stages the uterus is enlarged, 
sometimes irregularly. The finger may be pushed through the external 
OS with ease and friable, necrotic material felt within the endometrial 
cavity. Early, the condition must be diagnosticated from chronic endo- 
metritis, mucous polyp, small submucous fibroid, and beginning sar- 
coma. Later, from sloughing submucous fibroid and retained and 



Fig. 442 




Early cancer of the body of the uterus. The small area involved shows the importance of 
curettement in making an early diagnosis. It also emphasizes the fact that the operator should 
reach every part of the endometrium and furnish the pathologist with all of the tissue removed. 



putrefying placental tissue and advanced sarcoma. In any case where 
doubt exists, and this is frequent in early cases, the uterine cavity should 
he curetted and the scrapings should be submitted to a pathologist for 
diagnosis. It is important to curette the uterus thoroughly and reach 
every part of the endometrium, and to have every particle of the scrapings 
examined (Fig. 442). The curettings should be mounted and cut in 
celloidin or paraffin, and examined in the usual way. This can be 
accomplished wdthin thirty-six hours. If malignant trouble is found, a 
second operation can then be undertaken immediately. It is unwise to 
depend upon frozen sections of the endometrium in making a histological 
diagnosis. 

Sarcoma of the Uterus. — ^Primary sarcoma of the uterus is rare Sar- 
comatous degeneration occurs in about 1 per cent, of fibroid tumors, 
most often in the submucous variety. There is almost nothing symp- 
tomatic to distinguish between primary sarcoma of the uterine body 



724 GYNECOLOGICAL DIAGNOSIS 

and carcinoma. The clinical significance of each is the same. The 
microscope only can decide between them positively. The following 
facts in regard to a fibroid tumor may be indicative of sarcomatous 
degeneration: the patient is advanced in years; the tumor is submucous 
in position; there is a sudden increase in the size of the tumor and a 
coincident increase of hemorrhage and discharge. 

Fibroid Tumor of the Uterus. — Fibroid tumor is the commonest neo- 
plasm of the uterus. It occurs during the period of menstrual activity, 
from the thirtieth to the forty-fifth year. It is more frequent in sterile 
or single women and in the colored race. Fibroid tumors may affect 
any part of the uterus, but they are much less likely to occur in the cervix. 
From their position in the uterine wall, fibroid nodules are spoken 
of as subperitoneal, intramural, or submucous. 

Symptoms. — The chief symptom is hemorrhage. This is manifested at 
first as an increase in the amount or the duration of the menstrual flow. 
As a rule, the symptom grows worse gradually, and finally bleeding occurs 
between the periods. In some cases there is little hemorrhage. Hemor- 
rhage is most severe in the submucous variety. In such a case the blood 
may be retained for a time inside the uterus, and may then come away in 
clots and be partly decomposed. Leucorrhea may be present and is at first 
thin and watery ; later the amount of leucorrhea is obscured by the more 
or less constant hemorrhage. In necrotic submucous fibroids the discharge 
is putrid. Pain depends upon the position and the size of the tumor. 
Severe dysmenorrhea may be produced even by small tumors situated 
in the wall of the uterus. A submucous tumor may cause labor-like 
pains from uterine contractions made in an effort to expel it. There is 
also pain from the pressure which a tumor may exert upon the surrounding 
structures. Sciatic or crural neuralgia, backache, and a feeling of 
weight and dragging in the pelvis are not at all unusual. Frequent, 
painful, and difficult micturition or incontinence of urine may occur. 
Constipation is frequently observed. There are very often circulatory 
symptoms in cases of fibroid tumor. They result from impoverishment 
of the blood and from obstruction to the pelvic circulation. The cardio- 
vascular symptoms are manifested by palpitation of the heart, shortness 
of breath, hemic murmurs, edema, and varicosities of the lower extremi- 
ties. The anemia in fibroid tumor depends, in uncomplicated cases, 
largely upon the amount of blood lost. The skin is yellowish white, and 
the woman does not have a cachectic appearance. On the contrary, 
many patients grow fat. 

Diagnosis. — Abdominal Examination. — A fibroid tumor may be of 
sufficient size to rise above the pelvic brim and produce an en- 
largement of the abdomen. Such an abdominal enlargement must be 
differentiated from pregnancy and from an ovarian cyst. On inspec- 
tion the distention of the abdomen produced by a fibroid is apt to be 
found asymmetrical; it is more prominent on one side than on the other, 
or it occurs entirely to one side of the median line. The surface of the 
abdominal wall above the tumor drops suddenly to its normal level. On 
palpation inspection is confirmed. The fibroid tumor is hard and some- 



THE UTERUS 



725 



what resilient. The surface of the growth is frequently knobby and 
small tumors on the surface of larger ones may sometimes be felt. If it 
can be determined by palpation that these smaller tumors are peduncu- 
lated, the diagnosis is all but positive. Percussion of a fibroid tumor 
distending the abdomen gives dulness over the prominence of the tumor 
and resonance surrounding it, except toward the pelvic brim. There are 
no auscultatory indications of a fibroid. If the fibroid is intramural and 
distends the uterus symmetrically, it may be impossible to distinguish it 
from early pregnancy. In such cases it is advisable to keep the patient 
under observation until fetal movements and fetal heart sounds would 
have become manifest if the woman were pregnant. It should be remem- 
bered also that pregnancy and fibroid tumor may co-exist. 



Fig. 443 




Fibroid tumor of the uterus distending the abdomen. Note the slightly irregular outline and 
the abrupt fall of the surface line from the upper pole of the mass to the epigastrixma. The 
abdominal wall is pushed out by the hard, unyielding mass within. 



Bimanual Paljpation. — Submucous Tumors. — The uterus is enlarged and 
more or less symmetrical. It is harder than the pregnant uterus. If the 
tumor is pedunculated it sometimes dilates the cervix and presents itself 
in the cervical canal, or it may be extruded from the canal and hang by its 
pedicle in the vagina. In the case of small submucous tumors a positive 
diagnosis can be made only after dilatation of the cervix and intra-uterine 
exploration by means of the finger, sound, or curette. Interstitial tumors: 
The cervix fuses directly with the enlarged fundus. It sometimes projects 
from the surface of the latter like a nipple from the breast. The uterus 
is usually somewhat irregular and of increased density. The uterine 
body cannot be outlined distinctly from the mass. This form of tumor 
is most difficult to distinguish from pregnancy. Subperitoneal tumors: 
The uterus is studded with hard, knob-like protuberances. If they are 
pedunculated, the diagnosis is clear. When the growths are confined 
to one side of the uterus or to the fundus the uterus can be outlined as a 
distinct but attached body. When the tumor is single and pedunculated 



726 GYNECOLOGICAL DIAGNOSIS 

an ovarian growth must be excluded; an attempt should be made to 
isolate the ovary upon the affected side. If a subperitoneal fibroid, 
which rises out of the pelvis and distends the abdomen, is pushed up- 
ward by the external hand, the uterus will immediately follow. If the 
tumor is held in that position and the uterus is drawn downward, the 
pedicle of the tumor may be felt at its attachment to the uterus by rectal 
palpation. 

Tuberculosis of the uterus is usually complicated by tuberculosis of the 
tubes and of the pelvic peritoneum. The symptoms of the uterine trouble 
itself may resemble those of carcinoma. There may be a profuse leu- 
corrheal discharge containing cheesy particles. The body of the uterus 
may be considerably hypertrophied. A positive diagnosis can be made 
only by the microscopic examination of curettings. 

Inversion of the uterus dates from labor or the expulsion of a submucous 
pedunculated fibroid. The diagnosis rests upon the recognition of a 
pear-shaped tumor filling the vagina and covered with endometrium; the 
tubal ostia may be distinguishable. The cervix surrounds the pedicle of 
the tumor and the endometrial cavity is turned inside out. There is a 
cup-shaped depression at the fundus. 

Chorio-epithelioma of the uterus is an epithelial newgrowth arising from 
the chorion epithelium. Half of the cases are preceded by hydatidiform 
mole. The symptoms develop after abortion or labor and include a rapid 
enlargement of the uterus, hemorrhage, and a foul-smelling discharge. 
The growth rapidly extends locally, and metastases to the lungs and to 
other organs may occur very soon. The diagnosis depends chiefly upon 
a microscopic examination of pieces of the tumor secured by curettement. 
It is important to recognize the lesion without delay. 

Hematometra is a distention of the uterus with blood. It is usually 
associated with atresia of the vagina and hematocolpos. The uterus 
may be distended alone, the condition then resulting from an atresia 
of the cervix. Under these circumstances the uterus is frequently 
septate or bicornate, and the atresia and the hematometra affect one side. 
There are periodic colicky pains associated with menstrual molimina 
and a globular tumor in the lower abdomen. 

Pyometra and physometra exist when the uterus is distended with pus 
and gas respectively. They are almost invariably associated with 
carcinoma or sarcoma. The patient is septic and complains of colicky 
pains. The uterus is enlarged and sensitive. 



THE TUBES AND THE OVARIES. 

Malformations. — Hematosalpinx. — The tube is distended with blood; 
the condition may exist alone or in connection with hematometra or 
with hematometra and hematocolpos, as a consequence of some form 
of gynatresia. 

Elongation and twisting of the tube or a persistence of its fetal type 
favor tubal pregnancy and sterility. 



THE TUBES AND THE OVARIES 727 

Rudimentary or ill-developed ovaries have imperfectly formed follicles 
or none at all and are an occasional cause of sterility. 

Inflammations. — Acute salpingitis usually results from gonorrheal 
infection. Gonorrhea of the endometrium frequently extends to the 
tubes and from these in turn the infection progresses toward and in- 
volves the pelvic peritoneum. Acute gonorrheal salpingitis is usually 
associated with gonorrheal pelvic peritonitis. Its symptoms, diagnosis, 
etc., are found under that subject on page 728. 

Pyosalpinx is a distention of the tube with pus. It results from a 
suppurative inflammation of the mucosa with a coincident closure of the 
abdominal and the uterine ostia. The symptoms during the formative 
stage of the lesion are those of acute gonorrheal pelvic peritonitis (see 
p. 728). After full development and the subsidence of active inflam- 
matory processes, the symptoms, examination, etc., are those described 
under chronic pelvic peritonitis (see p. 729). 

Abscess of the ovary usually results from puerperal infection which 
reaches the ovary by way of the lymph channels. It may also be pro- 
duced by the extension of infection from an acute gonorrheal salpingitis 
to a Graafian follicle or a corpus luteum, or it may be formed by the 
bursting of a pyosalpinx into an adherent Graafian follicle or a cystic 
corpus luteum. The symptoms during the formative stage are those 
described under puerperal pelvic peritonitis, with which it is commonly 
associated (see p. 728). They are less apt to subside spontaneously 
than in gonorrheal salpingitis. If the inflammatory process becomes 
quiescent the symptoms resemble those of chronic pelvic inflammatory 
disease. 

Pelvic Inflammatory Disease. — Inflammatory affections of the tubes, 
the ovaries, and the pelvic peritoneum are so closely related and so fre- 
quently combined that they may be considered together. It is very 
often impossible to say, in a given case, which of the three is principally 
involved. A comparison of the conditions found at operation w^ith the 
cause of the inflammation has shown that certain forms of infection affect 
particularly certain organs. Thus, it is known that gonorrhea frequently 
produces pyosalpinx in pelvic inflammatory disease, and that sepsis 
following labor or instrumentation of the uterus does not, as a rule, pro- 
duce pyosalpinx. It is shown further that the last-mentioned form of 
infection is more apt to result in an ovarian abscess or in an inflammation 
of the cellular tissue of the broad ligaments. The pelvic peritoneum is 
usually involved in all forms of pelvic inflammation. With this explana- 
tion the various inflammatory affections of the tubes, the ovaries, and the 
pelvic peritoneum will be considered under the term pelvic peritonitis. 

Acute Pelvic Peritonitis. — Acute pelvic peritonitis may result from 
gonorrhea, from septic infection following abortion or labor, and from 
infection incident either to an operation upon the uterovaginal canal or 
to some instrumentation of the uterus. 

Gonorrheal Pelvic Peritonitis. — The symptoms usually begin during or 
immediately after a menstrual period. The patient gives the history of 
a leucorrheal discharge which originated after marriage or after suspi- 



728 GYNECOLOGICAL DIAGNOSIS 

cious intercourse. There are severe sharp pains in the lower abdomen, 
usually worse on one side. The menstrual flow may be arrested. Urina- 
tion is frequent and painful, the bowels are constipated; the abdomen is 
distended, and the abdominal muscles are tense or rigid. Nausea and 
vomiting may occur. The temperature varies between 101° and 103°; 
the pulse is increased proportionately; 110 to 120 beats per minute is not 
uncommon. 

Examination. — If no history confirmatory of gonorrheal infection can 
be elicited, Skene's glands, the vulvovaginal glands, and the cervix 
should be inspected for evidence of the disease, and if it is expedient 
smears should be made and examined for the gonococcus. Bimanual 
pelvic examination is unsatisfactory at first because of tenderness and 
rigidity. Usually it is possible to determine that the uterus is more or 
less fixed, and that any attempt to move it causes intense pain. After 
several days, under appropriate treatment, the pyrexia, the rapid pulse, 
and the abdominal tenderness and rigidity subside. Then, upon bi- 
manual palpation the uterus is found to be fixed, and back of it, on one 
or on both sides, induration is felt through the vault of the vagina. The 
pelvis contains inflammatory masses (pyosalpinx, tuboovarian abscess, 
encapsulated intraperitoneal abscess, pelvic exudate) which are immova- 
ble and very tender, and have a more or less globular or retort shape. 
From experience it is known that in the majority of cases of gonorrheal 
pelvic peritonitis a pyosalpinx is formed. The mass felt upon palpation, 
however, often consists of the tube, the ovary, and a peritoneal exudate 
bound together, and it is often impossible to determine to what extent 
each of these is involved. 

Differential Diagnosis between Gonorrheal Pelvic Peritonitis and Appen- 
dicitis. — In appendicitis there is often the history of a previous attack 
associated with an indiscretion in diet, or habitual overeating and chronic 
intestinal indigestion. Pain at first is not well localized, affecting more 
or less the entire upper abdomen. Later it is localized to the region of the 
appendix. The gastro-intestinal symptoms, nausea, vomiting, and 
constipation are more pronounced and less apt to respond quickly to 
treatment. Pain and tenderness are at a higher point and are more or 
less confined to the right side. There is no fixation of the uterus, and 
simple digital pelvic examination is not painful. 

Puerperal pelvic peritonitis dates from labor, abortion, or some intra- 
uterine operation or manipulation during pregnancy. It begins suddenly 
with a chill and hyperpyrexia (103° to 105°), or gradually, during the first 
few days of the puerperium. The pulse is usually increased out of pro- 
portion to the temperature. There may be no actual chills, but merely 
chilly sensations. There is pain in the lower abdomen, worse perhaps 
on one side; there is abdominal distention and more or less tenderness 
in the hypogastrium. Constipation is the rule early; later, in some of the 
most septic cases there is diarrhea. Nausea and vomiting are common. 
The lochia is usually diminished in amount. If necrotic material 
(placenta) exists inside the uterus the lochia will be putrid. In some of 
the worst cases the lochia does not have a foul odor. 



THE TUBES AND THE OVARIES 729 

Examination. — Palpation shows the uterus enlarged and the os patu- 
lous. Beyond this at first there is little information to be gained. Later 
the uterus is fixed and pelvic masses are found on one or both sides. 
They are more apt to be unilateral than in gonorrheal pelvic peritonitis. 
The vaginal vault and the pelvic masses have an almost stony hardness; 
later, if suppuration occurs, the masses soften. It is difficult often to 
differentiate an ovarian from a tubal enlargement, as there is a pelvic 
exudate which surrounds and envelops both the tube and the ovary. 
Ovarian abscess is more common than pyosalpinx in puerperal pelvic 
peritonitis. 

Instrumental or postoperative pelvic peritonitis follows operation upon 
the uterovaginal canal or instrumentation of the uterus. It may be a 
result of the extension of a gonococcus infection from the uterus to the 
tubes and the pelvic peritoneum. It may be produced by the direct 
introduction of infectious material (attempts to produce abortion) into 
the uterus. When due to the spread of gonorrhea, the symptoms are 
those, already discussed, of gonococcus pelvic peritonitis; when it 
follows the introduction of an unclean instrument into the uterus during 
pregnancy, the symptoms are those described under puerperal pelvic 
peritonitis (p. 728). If pregnancy actually did not exist and yet the 
uterus is infected, the symptoms will be less severe than in the puerperal 
form. 

Chronic Salpingitis. — See Chronic Pelvic Peritonitis. 

Adherent Tube and Ovary. — See Chronic Pelvic Peritonitis. 

Hydrosalpinx. — See Chronic Pelvic Peritonitis. 

Chronic pelvic peritonitis is the residuum of a previous acute peritonitis. 
Gonorrhea is more apt to produce it than puerperal infection. The latter, 
as a rule, either results in death or is entirely relieved by symptomatic or 
operative treatment. The former is not directly dangerous to life, but 
shows no tendency to spontaneous cure, and, unless the diseased organs 
are removed after the acuteness of the attack has subsided, they may 
continue to give trouble and be responsible for recurrent attacks of 
acute pelvic peritonitis. The lesions associated with chronic pelvic 
peritonitis comprise chronic pyosalpinx, hydrosalpinx, ovarian abscess, 
cystic enlargement of the ovary, tuboovarian abscess or cyst, intraperi- 
toneal collections of pus or serum, and adhesions which bind the pelvic 
organs together in malposition. When the pus originally present has 
been absorbed and serum has replaced it (hydrosalpinx, tuboovarian 
cyst, intraperitoneal cyst), the recurrence of peritonitis is less likely. 

Symptoms. — Backache, pain in the thighs and lower abdomen, pain 
during defecation, frequent and painful urination, irregularity of the 
menses, menorrhagia, dysmenorrhea, and persistent leucorrhea. In the 
case of chronic gonorrheal pyosalpinx there are repeated attacks of 
acute pelvic peritonitis. 

Examination shows fixation of the uterus with or mthout displace- 
ment. Adnexal masses are found to either side or behind the uterus. 
It is difficult to positively distinguish the tube from the ovary in cases 
where there is much distortion or many adhesions. Tubal enlargements 



730 GYNECOLOGICAL DIAGNOSIS 

are apt to be sausage-shaped, ovarian enlargements are spherical or 
elliptical, tuboovarian masses are re tort- shaped. 

Tuberculosis of the Tubes. — Tuberculosis of the tubes is usually sec- 
ondary to tuberculosis elsewhere, although it is more frequent than 
tuberculosis of any other part of the genital tract. Both tubes are 
affected as a rule, but the lesion may be farther advanced on one side. 
The diseased tube may have the form of an ordinary pyosalpinx, its true 
nature being recognized only by microscopic examination. More com- 
monly the enlargement is nodular, chalky yellow in color, and confined 
to distinct areas, the intervening parts appearing to be little affected. 
Miliary tubercles may be present on the serous coat. 

Symptoms. — The symptoms are not often distinctive, and, unless there 
is ascites or indications of tuberculosis in some other organ, its true 
nature may be unsuspected. In young virginal women tuberculosis is 
the most frequent cause of pelvic inflammatory disease. The symptoms 
in general resemble those of chronic pelvic peritonitis from which it is 
often indistinguishable before operation. 

Tubal Pregnancy. — ^Tubal pregnancy may affect primipara, but, as a 
rule, multipara in whom a considerable interval has elapsed since the 
birth of the last child. 

Symptoms. — Often in the early weeks the general and the local mani- 
festations are quite like those of normal pregnancy. There may be on 
the contrary very little or no evidence of pregnancy whatever. The 
menstrual symptoms are extremely variable. In the majority of cases 
the menstrual flow ceases for a period of from eight to twelve weeks. At 
ihat time, in connection with the death of the fetus or a rupture of the 
embryonic sac, there is a discharge of decidual tissue and blood from the 
uterus, and hemorrhage continues thereafter either at irregular intervals 
or continuously. After the second month, sometimes earlier, there are 
periodic pains in the lower abdomen on the affected side, or a numbness 
or an aching pain in the groin. The pain is caused by contractions of 
the uterus and the tube, or by the peritoneal irritation or pressure of 
the enlarging tube. There is commonly some slight degree of pyrexia — 
99° to 100°. The bladder is frequently irritable, and constipation may 
be marked. 

Rupture of the tube or tubal abortion is usually preceded by par- 
oxysmal cramp-like pains of great severity in one iliac region. At the 
time of rupture there is an agonizing stabbing pain on the diseased side, 
followed by indications of internal hemorrhage, rapid, running pulse, 
air hunger, dilatation of the pupils, and a cold, clammy skin. There 
may be no further complaint of severe pain, but the patient is paUid and 
bears an anxious expression. The severity and degree of the symptoms 
vary in relation to the amount of blood which has been lost and the 
strength of the patient. Tubal abortion may produce the same symp- 
toms as rupture. Usually the stabbing pain does not occur and the 
symptoms of internal hemorrhage are less marked. 

Examination before rupture shows an enlargement of the uterus rather 
less than would correspond to the duration of pregnancy. There are 



THE OVARY 731 

softening of the cervix, discoloration of the vagina, and the mammary 
changes of pregnancy; all may be less marked than usual or they may 
be absent entirely. Bimanual examination reveals a tubal enlargement 
to one side of the uterus. It may be small and freely movable in the 
early weeks and if no adhesions have formed; as a rule, there is a 
slightly adherent mass of some size, and the uterus is correspondingly 
displaced. 

Immediately after rupture has occurred the remains of the enlarged 
tube may be found by bimanual palpation to one side of or behind 
the uterus. Rupture causes a diminution in the size of the tubal 
enlargement, and in some cases almost nothing but. tenderness and 
an ill-defined sense of fulness will be distinguished by bimanual 
palpation. When the hemorrhage is intraperitoneal and large, the 
signs of free fluid in the peritoneal cavity may be elicited. After 
tubal abortion, in which the bleeding is slower and the blood coagulates, 
and in cases examined some time after rupture, bimanual examination 
will discover a pelvic mass which usually is back of the uterus, displacing 
it forward and upward and perhaps to one side. The mass is doughy 
and semisolid, and by rectal palpation a sensation will be imparted to 
the finger like that experienced in breaking up a thick jelly. It should 
be emphasized that bimanual palpation must be very gently performed 
in all cases of suspected tubal pregnancy; otherwise it may cause a rup- 
ture or abortion, or, if either has already occurred, it may retard the 
formation of a clot and cause renewed hemorrhage. 



THE OVARY. 

Prolapse of the Ovary .^ — Causes. — Prolapse of the ovary occurs either 
alone or in combination with retroposition of the uterus. In the former 
case chronic wasting diseases with loss of the pelvic fat and relaxation 
of the ligaments, increased weight of the organ because of cystic degen- 
eration, and small ovarian tumors are causes. Subinvolution of the 
infundibulo-pelvic ligaments may produce it. The left ovary is more 
often affected than the right. 

Symptoms. — Pain varying from a dull, heavy ache to a sharp, agon- 
izing sensation, with faintness and nausea. The pain is relieved by a 
recumbent posture. It is made worse by walking, coitus, and defeca- 
tion. After defecation it may last for several hours. Dysmenorrhea 
and menorrhagia may ensue. Reflex symptoms, such as headache, 
indigestion, nervousness, and mental depression, may be present. 

Examination. — Simple digital palpation of the vaginal vault to one 
side of the cervix discovers the ovary lying at the bottom of Douglas' 
cul-de-sac, or upon bimanual palpation it is found along the pelvic 
wall at a slightly higher point. Care must be taken to distinguish a 
prolapsed ovary from a fecal mass in the rectum or sigmoid. 

Cystic degeneration of the ovary or follicular cysts of the ovary result 
from an inflammation of the ovarian surface or from adhesions between 



732 GYNECOLOGICAL DIAGNOSIS 

the ovary and the pelvic peritoneum in chronic pelvic peritonitis. The 
fluid of maturing Graafian follicles which are prevented from undergoing 
the normal rupture is retained within the ovary. Cystic degeneration 
may also occur in a prolapsed ovary as the result of slow thickening 
of the ovarian capsule, due to the more or less constant mechanical 
irritation to which it is exposed; rarely there may be thickening of 
the ovarian capsule and cystic degeneration without any demonstrable 
cause. 

The symptoms and the objective signs are dependent upon the 
associated lesion, being usually like those of a chronic pelvic peritonitis 
or a prolapsed ovary. In the rare form which occurs without apparent 
reason the patient suffers from backache, pain in the ovarian region, 
severe dysmenorrhea, menorrhagia, and leucorrhea. Nervous symptoms 
are often pronounced. On palpation the ovaries feel larger than normal 
and are freely movable or slightly adherent. 

Ovarian Tumors. — Glandular cyst is the most common ovarian 
tumor, cystic or solid. It usually develops about the age of forty-two, 
although it may occur in the very young or the very old. Nullipara and 
multipara are equally susceptible. 

Symptoms. — There may be no indications of the tumor until it is 
large enough to distend the abdomen. Early symptoms are dysmen- 
orrhea and profuse menstrual flow. As the ovarian stroma is destroyed 
the periods become scanty. Pain is a variable symptom and usually 
depends upon torsion of the pedicle or adhesions. The bowels may 
be constipated and the bladder irritable. In large tumors, distending 
the abdomen, digestive disturbances are common; anorexia, nausea and 
vomiting, catarrhal jaundice, and intestinal obstruction have been 
noted. The heart may be embarrassed by the increase of intra- 
abdominal pressure and often there is considerable dyspnea. The 
abdominal wall is overstretched and very thin or edematous; dilated 
veins appear on the surface; edema of the vulva and of the lower 
extremities may be present. Hemorrhoids and ascites are not infrequent 
complications. With increasing impairment of nutrition there is 
progressive emaciation, and the face has a weazened appearance, the 
fades ovariana. 

Abdominal Examination. — Ovarian tumors which distend the abdo- 
men, must be differentiated from pregnancy, uterine fibroids, ascites, 
and an excessive accumulation of fat. Inspection: Large tumors distend 
the abdomen symmetrically, the greatest prominence being in the 
median line and the surface smooth and regular. The abdominal 
wall drops gradually from the umbilicus to the ensiform. Smaller 
tumors may lie more to one side than the other, but a median position 
is most common unless the cyst is adherent or intraligamentous. 
Palpation confirms inspection in regard to position. The tumor is 
neither so hard nor so distinctly outlined as a fibroid. A multilocular 
tumor may be slightly irregular, but it has no knob-like protuberances 
from the surface. Fluctuation may bp elicited in large tumors and in 
small ones which are unilocular and thin-walled. In large cysts the 



THE OVARY 



733 



percussion wave may be limited to certain areas (loculi), and in small 
multilocular growths with thick contents there may be little trans- 
mission of impulse. The percussion note is dull over the tumor and 
resonant around it (coronal resonance) except toward the pelvic brim. 



Fig. 444 




Ovarian cyst distending the abdomen. Note the regularity of outline, the general symmetry 
and the more gradual fall of the abdominal wall from the umbilicus to the epigastrium. 



Fig. 445 




Abdominal enlargement due to ascites. The peritoneal cavity is filled with fluid. The surface 
line of the abdomen shows a less abrupt projection than in the case of a fibroid tumor or an 
ovarian cyst. The distention also noticeably affects the flanks. 



Bimanual Palpation. — In small cysts a spherical mass is felt lateral to 
and behind the uterus, which is commonly displaced anteriorly and to 
the opposite side. The smaller the tumor the more it is found to one 



734 GYNECOLOGICAL DIAGNOSIS 

side and the less the uterus is displaced. The surface is quite regular, 
and fluctuation can usually be elicited by having a second person tap 
the abdominal fingers, when the tumor is palpated bimanually. In small 
multilocular tumors with thick contents fluctuation may not be very 
distinct. Unless the tumor is adherent or impacted in the pelvis, it can 
be displaced above the brim of the pelvis. The uterus may now be 
distinctly outlined as a separate body; it is usually normal in size. 
Moving the uterus up or down will not influence the position of the tumor 
to the same degree as is noted in subperitoneal pedunculated fibroids. 
A normal ovary cannot be felt upon the affected side. 

In the case of large ovarian cysts which fill the pelvis and distend the 
entire abdomen, it is very often impossible to palpate the body of the 
uterus, as it is pressed against the pelvic wall and partially enveloped 
by the lower pole of the tumor. In such cases a sound, passed with 
aseptic precautions may be used to determine the size and position of 
the uterus. 

Papillomatous ovarian cyst is often bilateral and does not usually 
reach an enormous size. There is little distention of the abdomen except 
by ascites, with which it is frequently complicated. Papillomatous, 
warty, or cauliflower-like masses may be felt through the vaginal vault, 
or perhaps through the abdominal wall, if the patient is emaciated. 

Parovarian Cyst. — A parovarian cyst is usually smaller than a glandular 
cyst. It is felt low in the pelvis in direct relation with the lateral border 
of the uterus, which is pushed to the opposite side. There may be some 
bulging of the vaginal vault on the affected side. There is no indura- 
tion. Fluctuation is usually distinct. In the case of a very large par- 
ovarian cyst distending the abdomen the surface is smooth and fluctua- 
tion is very distinct over the entire tumor. 

Dermoid Cyst. — Dermoid cysts do not attain the size of glandular cysts. 
They may develop about the age of puberty. The physical signs are 
those of the smaller glandular cysts, but they are prone to become 
adherent, so that fixation and induration of the surrounding tissues are 
not uncommon. Fluctuation is not distinct, but the tumors have a 
semisolid, putty-like consistency. 

Accidents to Ovarian Cysts. — Acute torsion of the pedicle of an ovarian 
cyst is marked by sudden extreme pain in the lower abdomen, symptoms 
of collapse, and slight enlargement of the tumor. Rupture of an ovarian 
cyst is evidenced by severe pain, the general symptoms of shock, and a 
complete or partial disappearance of the tumor. The severity of the 
symptoms depends upon the extent of the rupture and the amount of 
hemorrhage. Serous contents are absorbed; thick mucilaginous con- 
tents may cause low grade peritonitis and ascites; if the cyst is papil- 
lomatous, the warty masses will become transplanted to the general 
peritoneum. 

Solid Tumors of the Ovary. — Fibroma, sarcoma, carcinoma, and papil- 
loma may occur. All are rare. A majority of the solid ovarian tumors 
are sarcomata. The symptoms are those produced by pressure and by 
peritoneal irritation. They are most apt to be confused with single, 



THE BLADDER AND URETHRA 735 

subperitoneal, pedunculated, fibroid tumors of the uterus. A body 
corresponding to the position and size of the normal ovary cannot be 
felt upon the affected side. 

THE BLADDER AND URETHRA. 

Genital Fistula. — A number of varieties are encountered; the vesico- 
vaginal and the rectovaginal are the commonest. Other varieties are: 
urethrovaginal, vesico-uterine, vesicoutero-vaginal, ureterovaginal, and 
uretero-uterovaginal. 

A vesical fistula may be caused by the delayed or improper use of for- 
ceps in a difficult labor. It may follow vaginal hysterectomy, cancer, 
syphilis, tuberculosis, or ulceration produced by a foreign body, such 
as a pessary, in the vagina. 

Symptoms. — Onset. Difficulty in urination followed by hematuria, 
febrile disturbance, and vaginal discharge; after the sloughing tissue has 
been cast off there is an escape of urine which is more or less constant 
but which may vary according to the posture of the patient and the site 
of the fistula. The vagina is excoriated and encrusted with deposits of 
urinary salts; there are excoriations of the external genitalia and the 
inner surface of the thighs ; the urine undergoes ammoniacal decomposi- 
tion and has a foul odor. Emaciation, depression of spirits, and general 
ill-health occur. 

Examination: Fistulous openings may be hard to find. Smaller fistulse 
must be searched for among the vaginal folds with a Sims speculum and 
a probe. A sound or a probe in the bladder may be passed through the 
fistula or the bladder may be distended with milk or with methylene- 
blue solution while the anterior vaginal wall is exposed to view. Large 
fistulse are easily found; they are surrounded by scar tissue, and the 
vesical mucosa sometimes prolapses through the opening. 

Rectovaginal fistula may be caused by laceration during childbirth, 
faulty plastic operation, tuberculosis, syphilis, or carcinoma. The 
fistula permits the passage of gas and liquid feces from the rectum to 
the vagina. 

Urethritis is usually due to gonorrhea; highly concentrated urine, 
irritating vaginal discharges, chemical irritants, and trauma are predis- 
posing causes and sometimes actually produce mild forms. 

The first symptom is frequent urination, accompanied by burning and 
scalding pain, with the occasional passage of a few drops of blood after 
urination. There is a purulent discharge from the urethra. 

Examination. — The external meatus is swollen and red, the mucosa 
bulging from the meatus like a prolapse of the urethra; the orifices of 
Skene's glands are conspicuous. Pus is present at the meatus unless 
urination has recently occurred. Pressure along the urethra will cause 
pus to appear. The urethroscope shows the mucosa swollen and red. 
In chronic urethritis all subjective symptoms are absent except perhaps 
frequency of urination. The urethroscope shows small ulcers or granular 
patches with little or no swelling of the mucous membrane between them. 



736 GYNECOLOGICAL DIAGNOSIS 

Urethral caruncle is the most frequent neoplasm of the urethra. It 
varies from a pale to a bright red color, resembling somewhat a raspberry; 
its size ranges from a pinhead to a hickory nut. It is usually found 
on the posterior wall of the urethra, just on the margin of or inside the 
meatus. The growth may be sessile or pedunculated, is exquisitely 
sensitive to touch, and bleeds readily. 

Symptoms. — There is pain during urination which lessens gradually, 
but sometimes lasts for ten or fifteen minutes. There is pain also on 
walking; coitus may be impossible. The suffering may be so great and 
so constant that the general health is seriously impaired. 

Suburethral Abscess. — There are the symptoms of an acute urethritis 
together with the presence of a tumor projecting into the vagina along 
the course of the urethra. The enlargement is extremely tender and 
upon pressure discharges its contents into the urethra. 

Cystitis. — Cystitis is produced by the extension of a urethritis, the 
trauma and the infection which may be incident to catheterization, 
retention of urine within a cystocele, a stricture or a neoplasm of the 
urethra, vesical calculus, exanthemata, or injuries. The acute form is 
produced by gonorrhea or infection from instrumentation. 

The symptoms are frequent and painful urination, pain, and a feeling 
of fulness in the bladder, vesical tenesmus, and slight bleeding at the 
end of urination. Tenderness is elicited by pressing on the base of the 
bladder through the vagina. On cystoscopic examination the mucosa 
is found to be covered with a thick, tenacious pus ; it is swollen and has 
a deep red color. There may be partial exfoliation of the mucosa. 
Catheterized specimens of urine show pus and blood. The subacute 
or chronic form is the residuum of an acute attack or is produced by 
milder grades of infection with retention and decomposition of the urine. 
Tuberculous cystitis may occur secondary to tuberculosis of the kidney. 

Symptoms. — There is more or less dull pain in the bladder region, 
frequent and painful urination, and tenderness on pressure over the base 
of the bladder. Cystoscopic examination shows the mucosa of a dirty 
or grayish red color, covered with mucopurulent discharge, and areas of 
erosion or actual ulcers scattered over it. The lesions often are confined 
largely to the vesical trigone. A catheterized specimen of urine is alka- 
line and contains mucus, pus, bladder epithelium, and perhaps blood. 

Vesical calculus is less frequent in women than in men because of the 
greater diameter and shortness of the urethra. The symptoms of the 
disorder differ in no wise from those in the male. A large stone may be 
felt by bimanual palpation. 

Gonorrhea. — Gonorrhea in the female does not have the violent initia- 
tive course which it has in the male. In sluggish or in uncleanly women 
the disease may exist for some time before being observed; it usually starts 
in one of three localities, or in two or all of them combined, viz., the 
urethra, the vulvovaginal glands, and the cervix. A coincident sup- 
purative inflammation of the three is highly suggestive of gonorrhea. 
Gonorrhea usually is first evidenced by the symptoms of urethritis which 
continue for a few days and then subside. Chronic suppuration persists 



THE BLADDER AND URETHRA 737 

in Skene's tubules, the ducts of the vulvovaginal glands, and the cervix. 
Acute vulvitis rarely develops from the initial infection except in the 
young. 

Gonorrhea is most apt to extend to the endometrium, and from there 
to the tubes and the pelvic peritoneum, during or after a menstrual 
period or after labor. The symptoms and the diagnosis of the various 
lesions of gonorrhea (vulvitis, cervical catarrh, endometritis, salpingitis, 
peritonitis) have already been described. 

The gonococcus may be detected in smears taken directly from Skene's 
tubules, the vulvovaginal ducts, and the cervix. Although the coincident 
infection of the urethra, vulvovaginal glands, and the cervix, and the 
presence of gonorrheal macules at the orifices of Skene's tubules and the 
vulvovaginal glands constitute almost undoubted evidence of gonorrhea; 
still, in a forensic sense, at least, the diagnosis is not positive until the 
specific organism has been found. 



47 



INDEX. 



Abdomen, contusions of, 477 

foreign bodies in, a:-rays in, 64 
Abdominal aneurysms, a;-rays in, 64 
examination, 700 
muscles, rupture of, 488 
parietes, abscess of, 488 
retention of testicle, 651 
swellings, left lower quadrant, 498 

right lower quadrant, 497 
tumors, 486 

a:-rays in diagnosis of, 65 
wall, actinomycosis of, 488 

carcinoma of, 489 

cellulitis of, 487 

cysts of, 489 

edema of, 487 

emphysema of, 487 

fibroma of, 488 

gumma of, 488 

hernia of, 487 

lipoma of, 488 

sarcoma of, 489 

swellings of, 487 

syphilis of, 488 
Abducens nerve, functions of, 152 

paralysis of, 152 
Abscess of abdominal parietes, 488 
of anus, 546 
of axilla, 438 
of brain, 169, 236 
of buttocks, 633 
cold, 452 
of groin, 638 
ihac, 497 
ischiorectal, 547 
of liver, 495, 519 
of lungs, 459 

a;-rays in, 61 
of ovary, 727 
of palate, 299 
palmar, 360 
of pancreas, 526 
of penis, 646 
perinephric, 497 

rc-rays in diagnosis of, 63 
peritonsillar, 296 
psoas, 497, 615 
retropharyngeal, 298 
of roots of teeth, 290 
of scrotum, 649, 650 
of spleen, 499 



Abscess of stomach, 493 

sublingual, 310 

submammary, 466 

subphrenic, 495, 499 

re-rays in diagnosis, 62 

suburethral, 736 

supramammarv, 466 - 

of tibia, 591 

of umbilicus, 490 

of vulvovaginal glands, 712 
Acetonuria, 26 
Achilles jerk, 156 
Achondroplasia, 127 

x-rays in diagnosis of, 42 
Acne, 85 

rosacea of nose, 273 
Acromegaly, 127 

.T-rays in diagnosis of, 42 
Acromial bursitis, 442 
Acromiocla^^cular dislocations, x-rays in 

diagnosis of, 47 
Actinomycosis, 76 

of abdominal wall, 488 

of cecum, 498 

of face, 250 

of intestines, 538 

of jaw, 284 

of lung, 459 

of Ijonph glands, 305 

of neck, 315 

of peritoneum, 480 

of spine, 343 

of tongue, 294 
Addison's disease, 692 
Adductor tubercle, fracture of, 603 
Adenitis, acute, 310, 414 

of axilla, 439 

cervical, 311 

chancroidal, of groin, 639 

chronic, 104 

phagedenic, 105 

submaxillary, 310 

submental, 310 

syphilitic, 104 

tuberculous, 105 

of axillary glands, 442 
of groin, 639 
Adenoid growths, 278 
Adenoma of brain, 168 

of face, 253 

of lips, 281 
A.denopathy of neck, gummatous, 316 
' ilitic, 316 



740 



INDEX 



Adrenal gland, tuberculosis of, 692 
Alar ligaments, contusion of, 599 
Albuminuria, 24 
Amastia, 464 
Amenorrhea, 697 
Amyloid degeneration, 531 
Amytrophic lateral sclerosis, 197 
Anemia, 18 

pernicious, 18 
Aneurysm, 98 

of aorta, 321, 462 

arteriovenous, 99 
of neck, 321 

cirsoid, 99 

of external carotid artery, 321 

of femoral artery, 616 

of iliac artery, 497 

of internal carotid artery, 321 

of neck, 320 

of popliteal artery, 609 

of renal arteries, 691 

of scalp, 238, 239 

of subclavian artery, 321 

x-rays in diagnosis of, 59 
abdominal, 64 
traumatic, 66 
Angioma, 99 

cavernous, 99 

of conjunctiva, 263 

of eyelids, 260 

of foot, 579 

of forearm, 384 

of hand, 368 

of lips, 280 

of liver, 519 

of muscles, 110 

of nasopharynx, 279 

of orbit, 264 

of scalp, 238 
Angioneurotic edema, 90, 246 

gangrene, 100 
Ankle, bones of, fractures of, 564 
inflammation of, 575 

clonus, 156 

dislocations of, 570 

gumma of, 578 

joints of, arthritis of, acute, 575, 576 
chronic, 577 
post-traamatic, 577 
tuberculous, 577 
inflammation of, 575 

sprains of, 564 

trauma of, 564 
Ankylosis of hip, 622 

of knee, 598 
Anus, abscess of, 546 

chancroids of, 549 

congenital malformations of, 545 

dermatitis of, 545 

eczema of, 545 

epithelioma of, 550 

fissures of, 547 

fistula of, 548 

tuberculous, 548 

fistulous opening of, 547 

folliculitis of, 546 



Anus, papilloma of, 549 
prolapse of, 551 
pruritus of, 546 
syphilis of, 549 
tuberculosis of, 549 
tumors of, 549 

malignant, 550 
Anomalies of kidneys, 683 
of spinal column, 334 
of spleen, 529 
of testicle, congenital, 651 
of ureters, 679 
Anteflexion of cervix, 715 
Anthrax, 76, 91 
of face, 246 
Aorta, aneurysm of, 321, 462 
Ape hand, 347 
Aphasia, motor, 142 

sensory, 144 
AphthgB, 288 
Apoplexy, 160 
Appendicitis, acute, 540 
chronic, 542 

diagnosis of, from gonorrheal pelvic 
peritonitis, 728 
Areola, chancre of, 466 
eczema of, 466 
epithelioma of, 466 
furuncle of, 466 
Arm, angioma of, 448 

bones of, inflammation of, 445 
contusions of, 418 
fibrolipoma of, 447 
fibroma of, 447 
inflammations of, 438, 441 
joints of, inflammations of, 445 
lipoma of, 447 

nerves of, inflammation of, 442 
rupture of muscles of, 418 
sarcoma of, 447 
traumatism, of, 418 
tumors of, 447 
wounds of, 418 
Arteriosclerosis, a:;-rays in diagnosis of, 66 
Arteriosclerotic gangrene of hand, 365 

pain of foot, 561 
Arteriovenous aneurysm, 99 

of neck, 321 
Arteritis, 96 
Arthritis, 132 

acute gonorrheal, 134 
gouty, 134 

of wrist, 366 
hemophilic, 136 
infectious, of hip, 628 
of joints of ankle, 575, 576 

of foot, 575 
of metatarsal joints, 576 
of metatarsophalangeal joints, 

576 
post-traumatic, of hand, 366 

of wrist, 366 
purulent, of infants, 136 
rheumatic, 134 
of elbow, 415 
of knee-joint, 610 



INDEX 



741 



Arthritis, acute rheumatoid, of hand, 366 
of wrist, 366 
serous, of shoulder, 440 
suppurative, of elbow, 415 

of shoulder, 440 
of tarsal joints, 576 
of tempo romaxillary articula- 
tion, 287 
traumatic, 133 
of elbow, 414 
of hand, 366 
of knee-joint, 609 
tuberculous, 135 
atrophic, a:-rays in diagnosis of, 50 
chronic, 136 

of elbow, 415 

gouty, 137 

of joints of ankle, 577 

of foot, 577 
of shoulder, 446 
traumatic, 136 

of knee-joint, 610 
of wrist, 366 
tuberculous, 137 
deformans, 632 
acute, 135 
chronic, 136 
fungous, of shoulder, 447 
gonococcal, of elbow, 415 
of hip, 628 
of knee-joint, 610 
gonorrheal, of hand, 366 

of wrist, 366 
influenza, 135 
neuropathic, 138 
of elbow, 416 
of knee-joint, 613 
of shoulder, 447 
osteomyelitic, of hip, 629 
pneumococcic, 135 

of hip, 629 
post-traumatic, of joints of ankle, 577 

of foot, 577 
rheumatic, of elbow, 415 
of hip, 628 

of temporomaxillary articula- 
tion, 287 
scarlet fever, 135 
serofibrinous, of shoulder, 440 
of spinal column, x-rays in diagnosis 

of, 58 
syphilitic, 138 

of elbow, 415 
of knee-joint, 612 
traumatic, of hip, 628 
tuberculous, of elbow, 415 
of hip, 629 
of joints of ankle, 577 

of foot, 577 
of knee-joint, 611 
of shoulder, 447 
of temporomaxillarv articula- 
tion, 287 
of wrist, 367 
t>7)hoidal, 135 
of hip, 628 



Arthritis, x-rays in diagnosis of, 49 
Arthropathy, syringomyelic, 138 

tabetic, 138, 579 
of hip, 632 

x-rays in diagnosis of, 53 
Aseptic fever, traumatic, 69 
Astragalus, dislocations of, 571 

fracture of, 565 
Ataxia, locomotor, 197 
Athelia, 464 
Atresia of urethra, 707 

of vagina, 707, 713 
Atrophic arthritis, x-rays in diagnosis of, 
50 

rhinitis, 274 
Atrophy of breast, 465 

of muscles. 111 
Auditory meatus, furuncles of, 255 
inflammations of, 255 

nerve, functions of, 152 
Auricle, congenital deformities of, 254 
Axilla, abscesses of, 438 

adenitis of, 439 

carcinoma of, 448 

eczema of, 438 

lipoma of, 448 

lymphangioma of, 448 

sarcoma of, 448 

tinea of, 438 
Axillary glands, inflammatory hyper- 
plasia of, 442 
tuberculous adenitis of, 442 



Bacteriuria, 671 
Balanoposthitis, 642 
Banti's disease, 531 
Bayonet finger, 351 
Bell's palsy, 216 
Benee-Jones' body in urine, 25 
Biceps bursitis, 608 

clonus, 156 

muscle, syphilis of, 441 

reflex, 156 
Bicornate uterus, 720 
Bile pigment in urine, 27 
Biliary calculus, x-rays in, 64 
Birth injuries of head, 227 
Bladder, calculi of, 675 

carcinoma of, 678 

centres of spinal cord, 193 

contusion of, 673 

exstrophy of, 672 

foreign bodies in, 678 
x-rays in, 64 

hernia of, 672 

inflammation of, 674 

malformations of, 671 

malpositions of, 671 

rupture of, 673 

trauma of, 673 

tuberculosis of, 678 

tumors of, 494, 678 

wounds of, 673 



742 



INDEX 



Blastomycotic ulcers of leg, 583 
Blepharitis, 259 
Blindness, letter, 144 

word, 144 
Blood, coagulation of, 17 
cystsof neck, 318 
effusions, diffuse, 491 
examination of, 17 
in urine, 26 
Bloodvessels, contusions of, 96 
inflammation of, 96 
rupture of, 96 
trauma of, 96 
tumors of, 99 
wounds of, 96 
Bones, 118 

of ankle, fracture of, 564 

inflammation of, 575 
of arm, inflammation of, 445 
carcinoma of, 130 

a;-rays in diagnosis of, 45 
chondroma of, 128 
contusion of, 118 
cranial, fracture of, 227 

gumma of, 234 

indentation of, 227 
cysts of, 130 

x-rays in diagnosis of, 44 
disease of, fat embolus and, 130 

x-rays in diagnosis of, 37 
endothelioma of, 129 
fibrochondroma of, 117 
fibroma of, 130 
of fingers, dislocations of, 357 

fractures of, 352 
of foot, fractures of, 564 

inflammation of, 575 
fracture of, 118 

ununited, 120 
of hand, dislocation of, 357 

fractures of, 352 

inflammations of, 366 
hyoid, fracture of, 308 
hypernephroma of, 130 
inflammation of, 120, 122 

rc-rays in diagnosis of, 39 
of leg, fracture of, 584 

inflammation of, 587 
lipoma of, 128 
malar, fracture of, 245 
myeloma of, 129 
osteoma of, 127 
Paget's disease of, 127 
sarcoma of, 129 

x-rays in diagnosis of, 41, 43 
of shoulder, inflammation of, 445 
of skull, fracture of, 227 
syphilis of, hereditary, x-rays in diag- 
nosis of, 42 

x-rays in diagnosis of, 40 
trauma of, 118 
tuberculosis of, x-rays in diagnosis of, 

39 
tumors of, 127 

x-rays in diagnosis of, 43 
of wrist, dislocations of, 357 



Bones of wrist, fractures of, 352 

inflammations of, 366 
/?-oxybutyric acid in urine, 26 
Brachial neuralgia, 220 
neuritis, 219 
palsy, 220 

plexus, contusions of, 308 
Brain, abscess of, 169, 236 
adenoma of, 168 
carcinoma of, 167 
cholesteatoma of, 168 
compression of, 185, 225 
concussion of, 224 
contusions of, 223 
cysts of, 168 

traumatism and, 168 
diseases of, 135 

alterations in mentality in, 163 

apoplexy in, 160 

convulsions in, 154 

disturbance of motility in, 153 
of sensation in, 162 
of special senses in, 163 
of vision in, 163 

dizziness in, 153 

epilepsy in, 154 

forced movements in, 154 

headache in, 153 

hemiplegia in, 158 

idiocy in, 163 

imbecility in, 163 

insanity in, 163 

nausea in, 153 

paralysis in, 155 

reflexes in, 155 

tremors in, 154 

vertigo in, 153 

vomiting in, 153 
endothelioma of, 164 
fibroma of, 167 
frontal lobe of, tumors of, 171 
glioma of, 165 
gumma of, 166 
injuries of, 185 

terminal effects of, 187 
internal capsule of, 145 
lipoma of, 168 

meninges of, diseases of, 201 
motor centres of, 142 

tumors of, 174 
occipital area of, tumors of, 176 
osteoma of, 168 
osteosarcoma of, 164 
psammoma of, 168 
psychical centres of, 144 
sarcoma of, 164 
sensory centres of, 142 

tumors of, 175 
subcortical centres of, 145 

tumors of, 178 
syphilis of, 166 

temporal lobes of, tumors of, 177 
tuberculosis of, 165 
tumors of, 163 

x-rays in diagnosis of, 55 
visual centres of, 144 



INDEX 



743 



Brain, visual centres of, tumors of, 176 
Branchial cysts, 317 

fistulae, 306 
Breast, abscess of, 464, 466 

actinomycosis of, 464 

atrophy of, 465 

chancre of, 464, 466 

cysts of, 468 

diseases of, general symptomatology 
of, 464 

ecchymosis of, 470 

eczema of, 464, 466 

epithelioma of, 464, 466 

erosion of, 464 

fissure of, 464, 466 

furuncle of, 466 

gumma of, 464, 468 

hypertrophy of, 465 

inflammation of, 467 

malformations of, 464 
congenital, 464 

syphilis of, 468 

tuberculosis of, 464, 468 

tumors of, 464, 468 
Bronchi, foreign bodies in, 323 

a:-rays in diagnosis of, 59 
Bronchiectasis, 459 
Brown-Sequard paralysis, 200 
Bunion, a:-rays in diagnosis of, 54 
Burns of larynx, 323 
Bursse, 115 

enchondroma of, 117 

gumma of, 116 

inflammation of, 115 

m3rxoma of, 117 

sarcoma of, 117 

of shoulder, inflammation of, 442 

subdeltoidean, inflammation of, 
acute suppurative, 439 

subhyoid, 319 

suprahyoid, 319 

syphilis of, 116 

tuberculosis of, 116 

tumors of, 117 
Bursitis, 115 

acromial, 442 

acute, 115 

biceps, 608 

chronic, 116 

of elbow, acute, 414 
chronic, 414 

gastrocnemius - semimembranous, 
607 

gummatous, 116 

ileopsoas, 628 

infrapatellar, 607 

ischiatic, 628 

of knee-joint, 607 

popliteal, 608 

prepatellar, acute, 607 
chronic, 607 
tuberculous, 607 

pretibial, 607 

retrocalcaneal, 574 

subcoracoid, 445 

subdeltoidean, 442 



Bursitis, syphilitic, 116 
trochanteric, 628 
tuberculous, 116 
.r-rays in, 66 

Buttocks, abscess of, 633 
contusions of, 633 
sarcoma of, 633 
wounds of, 633 



Calcaneum, fractures of, 565 
Calculi, biliary, x-rays in, 64 

nasal, 273 

of pancreas, 527 

of parotid gland, 301 

of prostate, 663 

a;-ravs in diagnosis of, 63 

renal, 684 

x-rays in diagnosis of, 62 

salivary, 291 

x-rays in diagnosis of, 55 

ureteral, 680 

vesical, 675, 736 

x-rays in diagnosis of, 63^ 
Callosities, 94 
Cancer. See Carcinoma. 

en cuirasse, 461 
Capillary hemorrhoids, 551 
Caput succedaneum, 227 
Carbolic acid gangrene of hand, 365 
Carbuncle, 91 

of face, 245 
Carcinoma of abdominal wall, 489 

of axilla, 448 

of bladder, 678 

of bone, 130 

x-rays in diagnosis of, 45 

of brain, 167 

of cecum, 498 

of cervix, 717 

of duodenum, 515 

of eyelids, 260 

of gall-bladder, 523 

of humerus, 449 

of inguinal glands, 639 

of intestines, 499, 537 

of jaw, 286 

of larynx, 325 

of liver, 495, 519 

of maxillary sinus, 276 

of neck, 314 

of orbit, 265 

of pancreas, 527 

of peritoneum, 481 

of rectum, 555 

of salivary gland, 305 

of scalp, 241 

of spine, 343 

of spleen, 531 

of stomach, 514 

of thigh, 618 

of thorax, 460 

of thyroid gland, 330 

of tongue, 294 



744 



INDEX 



Carcinoma of tonsils, 298 
of tympanum, 257 
of umbilicus, 489 
of ureter, 682 ^ 
of uterus, 722 
of vagina, 714 
of vulva, 710 4 ^ '< 
Cardiospasm, 473 ^ 1 1 

with diffuse dilatation of esophagus, 
474 
Caries of teeth, 289 

of vertebrae, x-rays in diagnosis of, 
57 
Carotid arteries, aneurysm of, 321 
body, 316 
tumor, 306 
Carpal bones, dislocations of, 358 

x-rays in diagnosis of, 47 
fractures of, 354 
Caruncle, urethral, 736 
Catarrh of cervix, 717 
Catarrhal pancreatitis, 526 

proctitis, acute, 550 
Cauda equina, 191 

tumors of, 206 
Cavernitis of penis, 641 
Cavernous angioma, 99 

bodies, induration of, 648 
Cecum, actinoniycosis of, 498 
carcinoma of, 498 
tuberculosis of, 498 
Celiotomy, postoperative complications 

of, 79 
Cellulitis, 75 

of abdominal wall, 487 
of fingers, 359 
of forearm, 382 
of hand, 358 
of leg, 583 
of penis, 641 
peritendinous, 112 
of scrotum, 649, 651 
of thorax, 451 
Cephalhematoma, 227 
Cephalocele, 243 
Cerebellum, 147 

tumors of, 179 
Cerebral pachymeningitis, 201 
peduncles, 145 
serous meningitis, 204 
Cerebrospinal meningitis, 202 
Cervical adenitis, 311 

nerves, diseases of, 21P 
neuralgia, 219 
rib, 308, 334 

x-rays in (iiagnosis of, 54 
Cervix, anteflexion of, 715 
carcinoma of, 717 
catarrh of, 717 
cystic degeneration of, 716 
double, 715 
eversion of, 716 
infantile, 715 
inflammation of, 717 
lacerations of, 716 
malformations of, 715 



Cervix, newgrowths of, 717 

pedunculated fibroid tumors of, 717 

polyps of, 717 

sarcoma of, 719 

septate, 715 

venereal warts of, 717 
Chalazion, 259, 260 
Chancre of areola, 466 

of breast, 464, 466 

of conjunctiva, 263 

of eyelids, 259 

of face, 247 

of hand, 362 

of lips, 279 

of nipple, 466 

of nose, 273 

of penis, 644 

of tongue, 293 

of tonsils, 297 

of vulva, 709 
Chancroidal adenitis of groin, 639 

urethritis, 669 
Chancroids of anus, 549 

of penis, 645 

of vulva, 709 
Charcot-Leyden crystals, 32 
Chilblain of foot, 561 
Choked disk, 151 
Cholangitis, fever of, 74 
Cholasma, 94 
Cholecystitis, 521 
Cholelithiasis, 521 
Cholesteatoma of brain, 168 

of ear, 257 
Chondroma of bone, 128 

of foot, 579 

of jaw, 285 

of nasopharynx, 279 

of rib, 461 

of sacro-iliac joint, 637 

of salivary gland, 304 

of skull, 242 

of sternum, 461 
Chorio-epithelioma of uterus, 726 
Chylothorax, 458 

Circumflex nerve, paralysis of, 221 
Cirsoid aneurysm, 99 
Clavicle, dislocations of, 438 

fractures of, 433 

gummatous osteitis of, 446 
Claw hand, 347 
Cloaca, persistent, 707 
Club foot, 560 
Coccygodynia, 634 
Coccyx, cysts of, 333 

tumors of, 333 
Cold abscess, 452 
Colles' fracture, 355 
Colon, diseases of, x-rays in, 66 
Compression of brain, 185, 225 
Concussion of brain, 224 

of chest, 453 
Condyles of femur, fracture of, 602 
Condyloid fractures, 397 
Congenital anomalies of intestines, 534 
of testicle,_651 



INDEX 



745 



Congenital anomalies of umbilicus, 489 
cysts of brain, 168 

of neck, 318 

of salivary glands, 304 
deformities of auricle 254 

of nose, 272 
dislocations of hip, 621 

rc-rays in diagnosis of, 47, 54 

of joints, 132 
fistula of auricle, 254 
macroglossia, 294 
malformations of anus, 545 
,^ of breast, 464 

of esophagus, 472 

of hand, 346 
^ of kidney, 497 
^ ",, of neck, 306 
2^ of penis, 640 

of rectum, 545 

of thorax, 451 
sacrococcygeal tumors, 633 
torticollis, 307 
tumors of neck, 307 
wry-neck, 307 
Congestion of spleen, 530 
of thyroid gland, 327 
of tympanum, 255 
Conjunctiva, angioma of, 263 
chancre of, 263 
cysts of, 263 
hyperemia of, 261 
inflanmaation of, 261 
lipoma of, 263 
polyps of, 263 
tumors of, 263 
xerosis of, 263 
Conjunctivitis, 261 

acute contagious, 261 
catarrhal, 261 
diphtheritic, 262 
diplobacillus, 262 
folUcular, 263 
gonorrheal, 262 
granular, 263 
phlyctenular, 263 
simple, 261 
Constipation fever, 73 
Contracture of hip, 622 

of internal vesical sphincter, 664 
of muscles, 111 
Contusions of abdomen, 477 
of alar ligaments, 599 
of arm, 418 
of bladder, 673 
of bloodvessels, 96 
of bones, 118 
of brachial plexus, 308 
of brain, 223 
of buttocks, 633 
of chest, 453 
of ear, 254 
of eye, 268 
of face, 245 
of foot, 564 
of hand, 346, 348 
of hip, 623 



Contusions of kidney, 684 
of knee, 598 
of larynx, 308, 322 
of leg, 584 
of muscles, 107 
of neck, 308 
of nose, 272 
of orbit, 263 
of penis, 640 
of scalp, 223 
of scrotum, 649 
of shoulder, 418 
of spine, 336 
of stomach, 510 
of testicle, 653 
of thigh, 614 
Conus meduUaris, 190 
Convulsions, 154 

Jacksonian, 154 
Cornea, foreign bodies in, 266 
inflammation of, 266 
ulcerations of, 266 
Corset liver, 518 
Cortical localization, 142 
Coryza, 273 

Costal cartilages, fracture of, 455 
Cowperitis, 668 
Coxa valga, 622 
vara, 622 

rc-rays in diagnosis of, 5 
Cranial bones, fracture of, 227 
gumma of, 234 
indentation of, 227 
nerves, 148 

diseases of, 215 
Cranium. See Skull. 
Cretinism, 326 

Crucial ligaments, rupture of, 599 
Cruroscrotal retention of testicle, 652 
Crus, 145 

tumors of, 178 
Crutch palsy. 111 
Cryoscopy, 24 
Curvature of spine, 335 

lateral, 335 
Cutaneous horns of eyelids, 260 

of face, 253 
Cj^stic degeneration of cervix, 716 
of ovarv, 731 
goitre, 320 ^ 
Cystitis, 674, 736 
Cystocele, 715 

Cysts of abdominal wall, 489 
of bone, 130 

a;-rays in diagnosis of, 44 
of brain, 168 
of breast, 468 
of cocc3^x, 334 
of conjunctiva, 263 
of epididymis, 656 
epithelial, of foot, 579 

of hand, 368 
of esophagus, 474 
of face, 252 
of jaw, 285 
of kidney, 691 



746 



INDEX 



Cysts of labial glands, 281 
of larynx, 325 
of lips, 281 
of liver, 519 
of lungs, 459 
of maxillary sinus, 276 
of mesentery, 493 
of muscles, 110 
of neck, 317 
of omentum, 493 
of orbit, 265 
of ovary, 734 

accidents to, 734 
of palate, 299 
of pancreas, 527 
parovarian, 734 
of penis, 469 
retroperitoneal, 492 
of sacrum, 334 
of salivary glands, 304 

congenital, 304 
of scalp, 240 
of scrotum, 650 
of seminal vesicles, 662 
of skull, 243 
of spinal cord, 206 
of spleen, 499, 531 
of suprarenal gland, 692 
of testicle, 656 
of thigh, 615 
of thyroid gland, 331 
of tongue, 296 
of urachus, 489 
of vagina, 714 
of vulvovaginal glands, 713 



Dacrocystitis, 261 
Dactylitis syphilitica, 363 

a:-rays in diagnosis of, 42 
Deformities of foot, 556 

of knee, 597 
Degeneration of spleen, 531 
Dental caries, 289 
Dentigerous cysts of bone, 130 

of jaw, 285 
Dermatitis of anus, 545 
of foot, 562 
of hand, 360 
of penis, 641 
Dermoid cysts of face, 252 

of liver, 519 

of neck, 318 

of orbit, 266 

of ovary, 734 

of penis, 648 

of skull, 243 

of spleen, 531 

of tongue, 296 
Diabetic gangrene, 100 

of hand, 365 
Diacetic acid in urine, 26 
Diaphragmatic hernia, 507 
Dilatation of stomach, acute, 511 



Diphtheritic conjunctivitis, 262 

laryngitis, 323 

proctitis, 550 

rhinitis, 273 

tonsiUitis, 297 

urethritis, 669 
Diplobacillus conjunctivitis, 262 
Dislocations of ankle, 570 

acromioclavicular, x-rays in diagnosis 
of, 47 

of astragalus, 571 

of carpal bones, 358 

x-rays in diagnosis of, 47 

of clavicle, 438 

of elbow-joint, 408 

x-rays in diagnosis of, 47 

of fibula, 606 

of foot, 570 

of forearm, forward, 412 
lateral, 412 

of hand, 357 

of hip, 626 

congenital, 621 

x-rays in diagnosis of, 47, 
54 
traumatic, x-rays in diagnosis of, 
47 

of humerus, 435 

of jaw, 287 

of joints, 131 

congenital, 132 

of knee-joint, 606 

of OS magnum, 358 

of penis, 641 

of radial styloid, 358 

radiocarpal, 357 

radio-ulnar, 358 

of radius, 412 

of semilunar bone, 358 

of shoulder- joint, 435 

x-rays in diagnosis of, 47 

of spine, 336 

of sternum, x-rays in diagnosis of, 
57 

subastragaloid, 571 

of tarsus, x-rays in diagnosis of, 49 

of tendons, 112 
of foot, 572 

of testicle, 653 

of tibia, 606 

tibiotarsal, 572 

of ulna, 412 

of ulnar styloid, 358 

of wrist, 357 

x-rays in diagnosis of, 46 
Displacements of uterus, 720 
Diverticula of esophagus, 475 

of intestines, 538 
Duchenne-Erb's paralysis, 220 
Duodenum, carcinoma of, 515 

ulcer of, 515 
Dupuytren's contracture, 346 
Dural sinuses, inflammation of, 235 
Dynamic ileus, 481 
Dysenteric proctitis, 550 
Dysmenorrhea, 698 



INDEX 



747 



Ear, auditory meatus, furuncles of, 255 
inflammation of, 255 
auricle of, congenital deformities of, 
254 
fistula of, 254 
tumors of, 254 
cholesteatoma of, 257 
contusions of, 254 
exostoses of, 256 
foreign bodies in, 255 
malformations of, 254 
middle, inflammations of, 256 
polyps of, 256 
tumors of, 256 

tympanic membrane of, cancer of, 
257 
congestion of, 255 
polypi of, 257 
wounds of, 254 
wounds of, 254 
Ecchymosis of breast, 470 
Echinococcus cvsts of bone, 130 
of brain, 168 
of face, 253 
of liver, 495, 519 
of lungs, 459 
of muscles, 110 
of spleen, 499 
of thyroid gland, 331 
Eczema, 84 

of anus, 545 
of areola, 466 
of axilla, 438 
of foot, 562 
of nipple, 466 
of nose, 273 
of penis, 641 
of scrotum, 649 
of umbilicus, 490 
Edema of abdominal wall, 487 
of glottis, 322 
of scrotum, 649 
Eighth nerve, functions of, 152 
Elbow, 386 

bursitis of, 414 
deformities of, 389 
dislocations of, 408 
fractures about, 393 
inflammations of, 414 
sprains of, 393 
traumatism of, 390 
wounds of, 390 
Elbow-joint, arthritis of, acute, 414 
gonococcal, 415 
rheumatic, 415 
suppurative, 415 
traumatic, 414 
chronic, 415 
neuropathic, 416 
syphilitic, 415 
tuberculous, 415 
dislocations of, rc-ravs in diagnosis 

of, 47 
inflammation of, 414 



Elephantiasis of nose, 273 

of penis, 647 

of scalp, 239 

of ^-ulva, 708 
Eleventh nerve, functions of, 153 
Embolic gangrene, 100 

of hand, 366 
Embolism, 96 
Emphysema of abdominal wall, 487 

of scrotum, 649 
Empyema of frontal sinus, 277 

a:-rays in diagnosis of, 62 
Encephalocele, 243 

of orbit, 266 
Encephalocystocele, 243 
Encephalohydrocele, traumatic, 230 
Enchondroma of bursa, 117 

of hand, 369 

of maxillary sinus, 276 

of muscles, 110 

a:-rays in diagnosis of, 45 
Endocarditis, acute ulcerative, fever of, 73 
Endometritis, acute, 721 

chronic, 722 
Endothelioma of bone, 129 

of brain, 164 
Enteritis, 485 

Epicondyle, fractures of, 400 
Epiconus, 191 
Epidid}Tnis, cysts of, 656 

inflammation of, 654 

tuberculosis of, 657 
Epidid5^mitis, urethral, 654 
Epilepsy, 154 

grand mal, 154 

petit mal, 155 

psychic, 155 
Epiphora, 260 

Epiphyseal separations, x-rays in diag- 
nosis of, 39 
Epiphysitis, acute, x-ra3's in diagnosis of, 

39 
Epispadia, 667, 707 
Epistaxis, 271 
Epithelial cvsts of foot, 579 

of hand, 368 
Epithelioma of anus, 550 

of areola, 466 

of eyelids, 260 

of face, 250 

benign cystic, 253 

of hand, 370 

of lips, 280 

of mouth, 289 

of nipple, 466 • 

of nose, 275 

of penis, 647 

of scalp, 241 

of scrotum, 652 

of skin, 95 

of thorax, 461 
Epitheliomatous ulcers of hand, 365 
Epuhs, 285 
Erysipelas 75, 91 

of face, 246 

of foot, 562 



748 



INDEX 



Erysipelas of leg, 583 

of nose, 272 

of penis, 641 

of scalp, 233 
Erysipeloid, 91 

of foot, 562 

of hand, 360 
Erythema intertrigo of foot, 561 
of penis, 641 
of scrotum, 649 

multiforme of foot, 561 

of nose, 273 ^ 
Erythematous lesions of skin, 91 
Erythrasma, 89 
Esophagismus, 473 
Esophagitis, acute, 472 
Esophagus, congenital malformations of, 
472 

cysts of, 474 

dilatation of, cardiospasm with, 474 

diseases of, 471 

ic-rays in diagnosis of, 65; 

diverticula of, 475 

foreign bodies in, 473 

x-rays in diagnosis of, 58 

inflammation of, 472 

papilloma of, 474 

polypi of, 475 

rupture of, 472 

stricture of, 474 

syphilis of, 474 

tuberculosis of, 474 

ulcers of, 474 

varices of, 474 
Ethmoid cells, inflammation of, 277 
Eversion of cervix, 716 
Exostoses of ear, 256 

of femur, 613 

of foot, 579 

of orbit, 264 _ 

of sacro-iliac joint, 637 

of spine, 343 

of tibia, 613 
Exstrophy of bladder, 672 
Exudates, examination of, 34 
Eye, contusion of, 268 

foreign body in, 268 

rc-rays in diagnosis of, 54 

muscles of, paralysis of, 268 
Eyelids, acute chalazion, 259 

angioma of, 260 

blepharitis of, 259 

carcinoma of, 260 

chancre of, 259 

cutaneous horns of, 260 

epithelioma of, 260 

furuncle of, 259 

herpes of, 259 

lupus of, 259 

milium of, 259 

molluscum contagiosum of, 260 

papilloma of, 260 

plexiform neuroma of, 260 

sarcoma of, 260 

stye, 259 

xanthoma of, 260 



Face, actinomycosis of, 250 

adenoma of, 253 

anthrax of, 246 

carbuncle of, 245 

chancre of, 247 

contusion of, 245 

cutaneous horns of, 253 

cysts of, dermoid, 252 
echinococcus, 253 
sebaceous, 252 

epithelioma of, 250 
benign cystic, 253 

erysipelas of, 246 

fibroma of, 251 

furuncle of, 245 

glanders of, 246 

gumma of, 248 

hemangioma of, 251 

inflammations of, 245 

lipoma of, 251 

lymphangioma of, 252 

malformations of, 244 

neuralgia of, 253 

sarcoma of, 252 

skin lesions of, 245 

syphilis of, 248 

tuberculosis of, 247 

tuberculous sinus of, 247 

tumors of, 250 
Facial nerve, functions of, 152 
paralysis of, 152 

neuralgia, 253 

palsy, 216 

spasm, 216 

tic, 216 
Fallopian tube, elongation of, 726 
inflammation of, 727 
malformations of, 726 
twisting of, 726 
Fat embolus, diseases of bone and, 130 
Feces, examination of, 28 

impaction of, 539, 552 
Femoral artery, aneurysm of, 616 

epiphysis, separation of, 603 

hernia, 505 
Femur, condyles of, fracture of, 602 

fracture of, 602 

neck of, fracture of, 624 

shaft of, fracture of, 616 
osteomyelitis of, 617 
Fever, 68 

of acute ulcerative endocarditis, 73 

of cholangitis, 74 

constipation, 73 

of follicular tonsillitis, 73 

hectic, 73 

of osteomyelitis, 73 

of otitis media, 73 

of thrombosis of kidney, 73 

traumatic aseptic, 69 
Fibrin in urine, 25 
Fibrochondroma of bursa, 117 
Fibroids of cervix, 717 

of uterus, 724 



INDEX 



749 



Fibrolipoma of arm, 447 
Fibrolymphangioma of scalp, 239 
Fibroma of abdominal wall, 488 

of arm, 447 

of bone, 130 

of brain, 167 

of face, 251 

of jaw, 285 

of larynx, 325 

of maxillary sinus, 276 

of nasopharynx, 278 

of neck, 317 

of nerves, 222 

of salivary gland, 304 

of scalp, 239 

of spinal cord, 206 

of tendons, 115 

of thorax, 460 

of tongue, 295 
Fibromyoma of vagina, 714 

of vulva, 712 
Fibrosarcoma of hand, 369 

of tendons, 115 
Fibula, dislocation of, 606 

fracture of, 584 

inflammation of, 587 

tuberculosis of, 592 
Fifth nerve, functions of, 152 

paralysis of, 152 
Fingers, bones of, dislocations of, 358 
fractures of, 352 

cellulitis of, 359 

inflammations of, 359 

sprains of, 349 
Fissures of anus, 547 

of breast, 464, 466 

of nipple, 466 
Fistula of anus, 548 

tuberculous, 548 

of auricle, congenital, 254 

branchial, 306 

genital, 735 

laryngeal, 324 

rectovaginal, 714, 735 

salivary, 305 

of ureter, 681 

vesical, 735 
Flat foot, 560 
Flipper hand, 348 
Floating liver, 494 

sj)leen, 499 
Focal irritation, 224 
Follicular tonsillitis, fever of, 73 
Folliculitis of anus, 546 
Foot, angioma of, 579 

arteriosclerotic pain of, 561 

bones of, fractures of, 564 
inflammation of, 575 

chilblain of, 561 

chondroma of, 579 

club, 560 

contusions of, 564 

cysts of, epithelial, 579 

deformities of, 556 

dermatitis of, 562 

dislocations of, 570 



Foot, eczema of, 562 
erysipelas of, 562 
erysipeloid of, 562 
erythema of, 561 
exostoses of, 579 
flat, 560 

gangrene of, 563 
hollow, 560 

joints of, arthritis of, acute, 575 
chronic, 577 
post-traumatic, 577 
tuberculous, 577 
keratosis of, 562 
lipoma of, 579 
lupus of, 563 
lymphedema of, 562 
Madura, 563 
painful, 560 
sarcoma of, 563, 579 
sprains of, 564 

tendons of, dislocation of, 572 
rupture of, 574 
• trauma of, 564 
tumors of, 579 
ulcers of, 563 

gummatous, 563 
perforating, 563 
urticaria of, 562 
Forearm, angioma of, 384 
celluUtis of, 382 
dislocations of, 412 
fractures of, 379 

of both bones, 380 
inflammations of, 382 
lipoma of, 384 
lymphangitis of, 382 
malformations of, 370 
muscles of, rupture of, 371 
neurofibroma of, 384 
osteomyelitis of, 383 
sarcoma of, 384 
syphilis of, 383 
tendons of, rupture of, 371 
traumatisms of, 371 
tuberculosis of, 384 
tumors of, 384 
wounds of, 379 
Foreign bodies in abdomen, x-rays in 
diagnosis of, 64 
in bladder, 678 _ 

.T-rays in diagnosis of, 64 
in bronchi, 323 

a;-rays in diagnosis of, 59 
in cornea, 266 
in ear, 255 
in esophagus, 473 

x-rays in diagnosis of, 58 
in eye, 268 

Arrays in diagnosis of, 54 
in head, x-rays in diagnosis of, 

54 
in larynx, 323 

x-rays in diagnosis of, 59 
in nose, 273 

in orbit, x-rays in diagnosis of, 
54 



750 



INDEX 



Foreign bodies in parotid gland, 302 

in pelvis, a;-rays in diagnosis of, 
64 

in pharynx, 298 

in rectum, 552 

in stomach, 511 

in submaxillary gland, 306 

in trachea, 323 

rc-rays in diagnosis of, 59 

in urethra, 667 
Fourth nerve, paralysis of, 152 
Fractures, 118 

of adductor tubercle, 603 

of astragalus, 565 

of bones of ankle, 564 

of fingers, 352 

of foot, 564 

of hand, 352 

of leg, 584 

of wrist, 352 
of calcaneum, 565 
of carpal bones, 354 
of clavicle, 433 
Colics', 355 
condyloid, 397, 400 
of coronoid process of ulna, 405 
of costal cartilages, 455 
of cranial bones, 227 
of elbow, 393 
of epicondyle, 400 
of femur, 602 

neck, 624 

shaft, 616 
of fibula, 584 
of forearm, 379 
of hip, 624 
of humerus, 395 

head, 421 

neck, 422, 423 " 

shaft, 419 

tuberosities, 422, 424 
of hyoid bone, 308 
intercondyloid, 402 
of jaw, 281 
of knee, 600 
of larynx, 308, 322 
of lower extremity of radius, 357 
of malar bones, 245 
of malleolus, 569 
of metacarpal bones, 353 
of nose, 272 
of olecranon, 405 
of orbit, 264 
of patella, 600 i 
of pelvis, 635 
of penis, 640 
Pott's, 568 
of radius, 380 

head, 405 

lower extremity, 355 

neck, 405 
of ribs, 454 

a;-rays in diagnosis of, 56 
of scapula, 430 

acromion process, 433 
coracoid process, 433 



Fractures of scapula, neck of, 433 
of skuU, 227 

anterior fossa, 228 
at base, 186, 228 
middle fossa, 229 
posterior fossa, 230 
of vault, 227 
of spine, 336 
of sternum, 454 

rc-rays in diagnosis of, 57 
supracondyloid, 396,. 402 
supramalleolar, 569 
of tarsal scaphoid, 565 
of tibia, 584, 604 
of ulna, 380 
of ulnar styloid, 357 
ununited, 118 

of vertebrae, x-rays in diagnosis of, 57 
ic-rays in diagnosis of, 37 
Fragilitas ossium, a;-rays in diagnosis of, 

42 
Freckles, 94 

Frontal lobe, tumors of, 171 
sinus, empyema of, 277 
inflammation of, 276 
tumors of, 277 
Fungous synovitis, 114 
Furuncle, 91 

of areola, 466 

of auditory meatus, 255 

of eyelid, 259 

of face, 245 

of hand, 358 

of nose, 272 

of scalp, 232 



Galactocele, 468 
Gall-bladder, carcinoma of, 523 

diseases of, rc-rays in, 64 

distention of, 520 

injuries of, 520 

stones in, 521 

tumors of, 496 
Ganglion of hand, 368 
Gangrene, angioneurotic, 100 

arteriosclerotic, of hand, 365 

carbolic acid, of hand, 365 

diabetic, 100, 365 

embohc, 100, 366 

of foot, 563 

of lungs, 459 

rc-rays in diagnosis of, 61 

senile, 100, 365 

symmetrical, 365 

traumatic, 99, 365 
Gangrenous stomatitis, 289 
Gastric contents, examination of, 33 
Gastritis, acute, 485 

chronic, 485 

sclerosing, 515 
Gastrocnemius-semimembranous bursitis, 

608 
Gastro-enteritis, 485 



INDEX 



751 



Gastroptosis, 512 
Genital fistula, 735 
Genu recurvatum, 597 

valgum, 597 

rc-rays in diagnosis of, 54 

varum, 598 

x-rays in diagnosis of, 54 
Gingi^dtis, 291 
Glanders, 77, 246 

Glands of neck, inflammation of, 319 
Glandular cysts of ovary, 732 
Glans clitoris, adhesions of prepuce to, 

708 
Glaucoma, acute, 267 
Glioma of brain, 165 
Glossitis, acute, 292 

Glossopharj^ngeal nerve, functions of, 152 
Glottis, edema of, 322 
Glucose in urine, 26 
Gluteal hernia, 633 
Goitre, cvstic, 320 

lingual, 295 

parenchymatous, 328 

vascular, of neck, 315 
Gonococcal arthritis of elbow, 415 
of hip, 628 
of knee-joint, 610 

urethritis, 668 
Gonorrhea in female, 736 

of sacro-iliac joint, 637 
Gonorrheal arthritis, 134 
of hand, 366 
of wrist, 366 

conjunctivitis, 262 

ophthalmia, 262 

osteoperiostitis, 121, 123 

pelvic peritonitis, 728 

diagnosis of, from appendi- 
citis, 728 

proctitis, 550 

spondylitis, 342 

tenosynovitis, 365 
Gouty arthritis, 134, 137, 366 

a:-rays in diagnosis of, 53 
Graves' disease, 327 
Groin, abscess of, 638 

adenitis of, chancroidal, 639 
tuberculous, 639 

inflammations of, 638 
Gumma of abdominal wall, 488 

of ankle, 578 

of brain, 166 

of breast, 464, 468 

of bursa, 116 

of cranial bones, 234 

of face. 248 

of hand, 364 

of larynx, 324 

of leg, 582 

of lips, 280 

of liver, 495, 519 

of muscles, 110 

of nose, 274 

of palate, 299 

of parotid gland, 305 

of pharynx, 299 , 



Gumma of ribs, 456 
of scalp, 234 
of sternum, 456 
of tendons, 115 
of tonsils, 297 
Gummatous adenopathy of neck, 316 
osteitis of clavicle, 446 

of himierus, 446 
osteoperiostitis of tibia, 588 
ulcers of foot, 563 
Gums, inflammation of, 291 
Gunshot injuries of thorax, a;-rays in 

diagnosis of, 59 
Gynecological diseases, constipation in, 
699 
fever in, 699 

occurring after puberty and 
during adolescence, 695 
before age of puberty, 694 
between ages of forty and 
sixty, 695 
of twenty-one and 
forty in married 
and non-virgin- 
al, 695 
of twenty-one and 
forty in unmar- 
ried and vir- 
ginal, 695 
pain in, 696 

location of, 696 
symptoms of, in detail, 696 
menstrual, 697 
onset of, 696 
Gynecomastia, 465 



Hematogenous nephritis, acute, 689 
Hallux rigidus, 557 

valgus, 557 

varus, 559 
Hammer finger, 351 

toe, 556 
Hand, abscess of, 360 

acute'gouty periarthritis of, 366 
post-traumatic arthritis of, 366 
rheumatoid arthritis of, 366 

angioma of, 368 

ape, 347 

bones of, dislocations of, 358 
fractures of, 352 
inflammation of, 366 

cellulitis of, 358 

chancre of, 362 

chronic traumatic arthritis of, 366 

claw, 347 

contractures of, 346, 348 

cysts of, epithelial, 368 

deformities of, 346 

dermatitis of, 360 

dislocations of, 357 

enchondroma of, 369 

epithelioma of, 370 

erysipeloid of, 360 



752 



INDEX 



Hand, fibrosarcoma of, 369 

flipper, 348 

furuncle of, 359 

ganglion of, 368 

gangrene of, 365, 366 

gonorrheal arthritis of, 366 

gumma of, 364 

joints of, inflammations of, 366 

keratitis of, 360 

lipoma of, 365 

paronychia of, 359 

psoriasis of, 360 

pulmonary osteo-arthropathy of, 348 

sarcoma of, 369 

soft parts of, inflammations of, 358, 
360 

sprains of, 349 

syphilis of, 367 

tuberculosis of, 364 

timiors of, 368 

ulcers of, epitheliomatous, 365 
syphilitic, 362 
traumatic, 362 
trophic, 365 
Harelip, 244 
Head, birth injuries of, 227 

foreign bodies in, a:-rays in diagnosis 
of, 54 
Heart, wound of, 454 
Heberden's nodes, 137 
Hectic fever, 73 
Heel, painful, 561 
Hemangioma of face, 251 
Hematemesis, postoperative, 80 
Hematocele, 657 
Hematoma of omentum, 493 

of vulva, 710 
Hematometra of uterus, 726 
Hematosalpinx, 726 
Hematuria, 26 
Hemiplegia, 158 

from injuries at birth, 159 
Hemoglobin, estimation of, 17 
Hemoglobinuria, 26 
Hemophilic arthritis, 136 
Hemorrhage, 78 

intracranial, 227 

of nose, 271 

of skin, 93 
Hemorrhoids, capillary, 551 

internal, 551 

thrombotic external, 546 

venous, 551 
Hepatic duct, stones in, 522 
Hereditary syphilis of bone, x-rays in 

diagnosis of, 42 
Hermaphrodism, 707 
Hernia, 500 

of abdominal wall, 487 

of bladder, 672 

diaphragmatic, 507 

external, 501 

femoral, 505 

gluteal, 633 

incarcerated, 501 

inguinal, 502 



Hernia, internal, 501, 507 
irreducible, 501 
ischiatic, 506 
Littre's, 507 
lumbar, 506 
of muscles, 108 

of thigh, 615 
obturator, 506, 638 
omental, 500 
perineal, 507 
Richter's, 507 
sciatic, 506 
strangulated, 501 
through linea alba, 461 
umbilical, 505 
ventral, 506 
Herpes of eyelids, 259 
of lips, 279 
of penis, 643 
vulvae, 709 
Hip, ankylosis of, 622 
arthritis of, 628 ^ 

acute infectious, 628 

gonococcal, 628 

osteomyelitic, 629 

pneumococcal, 629 

rheimiatic, 628 

traumatic, 628 

tuberculous, 629 

typhoidal, 628 
contracture of, 622 
contusions of, 623 
dislocations of, 626 

congenital, 621 
fractures of, 624 
malformations of, 621 
tabetic arthropathy of, 632 
trauma of, 623 
tumors of, 632 
Hodgkin's disease, 105, 532 
Hollow foot, 560 
Hour-glass stomach, 515 
Humerus, dislocations of, 435 
fractures of, 395 
gummatous osteitis of, 446 
head of, fractures of, 419 
neck of, fractures of, 422, 423 
osteomyelitis of, acute, 440 

chronic, 445 
sarcoma of, 448 
shaft of, fractures of, 419 
tuberculosis of, 445 
tuberosities of, fractures of, 422, 424 
tumors of, 448 
Hydatid cysts of abdominal wall, 489 

of breast, 468 

of spleen, 531 
Hydrocele, 654, 659 

of round ligament, 638 
of spermatic cord, 638 
Hydrocephalus, 243 
external, 169 
internal, 169 
Hydromyelia, 196 
Hydronephrosis, 496, 689 ; 
rc-rays in diagnosis of, 63 



INDEX 



753 



Hydrophobia, 77 
Hydrosalpinx, 729 
Hymen, imperforate, 707 
Hyoid bone, fracture of, 308 
Hyperemia of conjunctiva, 261 
Hj^pernephroma of bone, 130 

of kidney, 691 
Hyperplasia, chronic non-tuberculous in- 
flammatory, 104 

inflammatory, of axillary glands, 442 
of neck, 312 

of omentum, 291 
Hypertrophic arthritis, a;-rays in diag- 
nosis of, 50 

rhinitis, 274 

stenosis of pylorus, 512 
Hypertrophy of breast, 465 

of labial glands, 280 

of skin, 93 

of spleen, 530 

of tonsil, 296 
Hypoglossal nerve, functions of, 153 
Hypospadia, 666, 707 
Hysteria, traumatic, 212 
Hysterical joints, 139 
Hysteroneurasthenia, traumatic, 214 



Idiocy in diseases of brain, 163 
Ileopsoas bursitis, 628 
Iliac abscess, 497 

artery, aneurysm of, 497 
Imbecility in diseases of brain, 163 
Impacted teeth, 291 
Impaction of feces, 539, 552 
Imperforate hjmien, 707 
Impetigo, 92 
Incarcerated hernia, 501 
Infantile cervix, 715 
diplegia, 159 
palsy, 194 
paralysis, 159 
uterus, 720 
Infectious myositis, 108 
Infective osteomyelitis, 121, 123 

osteoperiostitis, acute, 121 
Inflamed skin tabs, 546 
Inflammations, 68 

acute suppurative, of subdeltoidean 

bursa, 439 
of arm, 438, 441 
of auditory meatus, 255 
of bladder, 674 
of bloodvessels, 96 
of bones, 120, 122 
of ankle, 575 
of arm, 445 
of foot, 575 
of hand, 366 
of leg, 587 
of shoulder, 445 
of wrist, 366 
a;-rays in diagnosis of, 39 
of breast, 467 
48 



Inflammations of bursa, 115 
of shoulder, 442 
of cervix, 717 
of chest, 455 
of conjunctiva, 261 
of cornea, 266 
of dural sinuses, 235 
of epididymis, 653 
of esophagus, 472 
of ethmoid cells, 277 
of face, 245 

of Fallopian tubes, 727 
of fibula, 587 
of fingers, 359 
of forearm, 382 
of frontal sinus, 276 
of glands of neck, 319 
of groin, 638 
of gums, 291 
of hand, 358, 360 
of intestines, 485 
of iris, 267 
of jaw, 284 
of joints, 132 

of ankle, 575 
of arm, 445 
of elbow, 414 
of foot, 575 
of hand, 366 
of knee, 610 
of sacro-iliac, 636 
of shoulder, 445 
of wrist, 366 
of larynx, 323 
of lips, 279 
of lymph glands, 303 
of maxillary sinus, 275 
of mediastinum, 456 
of middle ear, 256 
of mouth, 288 
of muscles, 108 
of nasopharynx, 278 
of neck, 310 
of nerves of arm, 442 
of shoulder, 442 
of nose, 273 
of orbit, 264 
of ovaries, 727 
of pancreas, 525 
of parotid gland, 302 
of penis, 641 
periarticular, 606 
of pericardium, 457 
of peritoneum, 477 

pelvic, 727 
of pharynx, 298 
' of pia arachnoid, 202 
of popliteal space, 607 
of prostate, 662 
of roots of teeth, 290 
of scalp, 232 
of seminal vesicles, 660 
of shoulder, 438, 441 
of skin, 84 
of skull, 232 
of sphenoidal sinus, 277 



754 



INDEX 



Inflammations of spinal cord, 198 
of spine, 340 
of spleen, 530 
of stomach, 485, 515 
of temporomaxillary articulation, 

287 
of tendons, 112 
of thoracic duct, 101 
of thyroid gland, 327 
of tibia, 587 
of tongue, 292 
of tonsils, 296 
of ureters, 680 
of urethra, 667 
of uterus, 721 
of vagina, 713 
of vulva, 707 

of vulvovaginal glands, 712 
of wrist, 358 
Inflammatory hyperplasia of axillary 
glands, 442 
chronic non-tuberculous, 104 
of neck, 312 
Influenzal arthritis, 135 
Infra-orbital neuralgia, 215 
Infrapatellar bursitis, 608 
Ingrowing toenail, 563 
Inguinal glands, carcinoma of, 639 
hernia, 502 

retention of testicle, 652 
Insanity in diseases of brain, 163 
Intercondyloid fractures, 402 
Intercostal neuralgia, 222 
Internal capsule, 145 
Interstitial keratitis, 267 
Intestines, actinomycosis of, 539 
carcinoma of, 499, 537 
congenital anomalies of, 534 
diseases of, general symptomatology 

of, 534 
diverticula of, 538 
inflammation of, 485 
lipoma of, 537 
myoma of, 537 
obstruction of, 481 

acute volvulus, 484 
dynamic ileus, 481 
intussusception, 484 
mechanical ileus without stran- 
gulation, 482 
obturation ileus, 481 
strangulation ileus, 482 
sarcoma of, 537 
small, diseases of, x-rays in, 66 
syphilis of, 536 
tuberculosis of, 538 
tumors of, 537 
ulcers of, 535 
Intra-abdominal swellings, 490 

of left upper quadrant, 499 
localized, 491 
Intracranial hemorrhage, 227 
Intraperitoneal swellings, 492 

of right lower quadrant, 497 
Intussusception, 484, 489 
Inversion of testicle, 652 



Inversion of uterus, 726 

Iodoform poisoning, 81 

Iris, inflammation of, 267 

Iritis, 267 

Irreducible hernia, 501 

Ischemic contracture of hand, 348 

Ischiatic bursitis, 628 

hernia, 506 
Ischiorectal abscess, 547 
Itch, 90 



Jacksonian convulsions, 154 
Jaws, actinomycosis of, 284 

acute osteoperiostitis of, 284 

carcinoma of, 286 

chondroma of, 285 

cysts of, dentigerous, 285 

epulis of, 285 

fibroma of, 285 

fixation of, 287 

fracture of, 281 

inflammation of, 284 

odontoma of, 285 

osteoma of, 285 

sarcoma of, 285 

syphilis of, 284 

tuberculosis of, 284 

tumors of, 285 

x-rays in diagnosis of, 55 
Joints, 131 

of ankle, arthritis of, acute, 575, 576 
chronic, 577 
post-traumatic, 577 
tuberculous, 577 
inflammation of, 575 

of arm, inflammation of, 445 

diseases of, x-rays in diagnosis of, 37 

dislocation of, 131 
congenital, 132 

of foot, arthritis of, acute, 575 
chronic, 577 
post-traumatic, 577 
tuberculous, 577 
inflammation of, 575 

free bodies in, 138 

of hand, inflammations of, 366 

hysterical, 139 

inflammations of, 132 

lipoma of, 139 

loose bodies in, x-rays in diagnosis 
of, 53 

metatarsal, arthritis of, 576 

metatarsophalangeal, arthritis of, 
576 

neurosis of, 139 

sacro-iliac, inflammation of, 636 
strain of, 635 

of shoulder, inflammation of, 445 

sprains of, 131 

tarsal, arthritis of, 576 

trauma of, 131 

wounds of, 131 

of wrist, inflammations of, 366 



INDEX 



755 



Keloid, 94 

Keratitis, interstitial, 267 
palmar, 360 
phlyctenular, 267 
vascular, 267 
Keratosis, 95 

of foot, 562 
Kidneys, anomalies of, 683 
calculi of, 684 
congenitally misplaced, 497 
contusions of, 684 
cysts of, 691 
hypernephroma of, 691 
movable, 496, 497, 683 
neoplasms of, 496 
papilloma of, 691 
suppurative diseases of, 687 
syphilis of, 691 
thrombosis of, fever of, 73 
tuberculosis of, 690 
tumors of, 496, 691 

rc-rays in diagnosis of, 63 
Knee, ankylosis of, 598 
bursitis of, 607 
contusions of, 598 
deformities of, 597 
fractures about, 600 
joints of, arthritis of, acute rheuma- 
tic, 610 
traumatic, 609 
chronic traumatic, 610 
gonococcal, 610 
neuropathic, 613 
sj^philitic, 612 
tuberculous, 611 
dislocation of, 606 
inflammation of, 609 
neuralgia of, 613 
tumors of, 613 
osteoarthritis of, 599 
sprains of, 598 
trauma of, 598 
wounds of, 598 
Knee-jerk, 156 
Kraurosis Aoilvse, 708 
Kyphosis, 336 



Labial glands, cj'sts of, 281 

hypertrophy of, 280 
Laboratory diagnosis, 17 
Lacerations of cervix, 716 
Lachrymal glands, enlargement of, 303 
Larvngeal nerve, recurrent, paralysis of, 

325 
Larjmgismus stridulus, 323 
Larv-ngitis, 323 

■"diphtheritic, 323 
Lar3^nx, burns of, 323 
carcinoma of, 325 
contusions of, 308, 322 
cysts of, 325 



Larynx, fibroma of, 325 

fistula of, 324 

foreign bodies in, 323 

a:-rays in diagnosis of, 59 

fracture of, 308, 322 

gumma of, 324 

inflammations of, 323 

lupus of, 324 

papilloma of, 325 

sarcoma of, 325 

scalds of, 323 

stenosis of, 324 

syphilis of, 324 

tuberculosis of, 324 

tumors of, 325 
Lateral curvature of spine, 335 

sclerosis, 197 

amyotrophic, 197 
Leg, bones of, fractures of, 584 
inflammation of, 587 

cellulitis of, 583 

contusion of, 584 

erysipelas of, 583 

gumma of, 582 

sarcoma of, 595 

tumors of, 595 

ulcers of, blastomj-cotic, 583 
chronic, 582 
S3''philitic, 583 
tuberculous, 583 

varicose veins of, 580 
Lentigo, 94 

Leptomeningitis, acute, 235 
Letter blindness, 144 
Leukemia, 21 

Ijonphatic, 21, 106, 313 

myelogenous, 21 
Leukemic enlargement of spleen, 531 ' 
Leukocytosis, 18 
Leukoplakia, 293 
Leucorrhea, 699 

mucopurulent, 699 

mucous, 699 

purulent, 699 

putrid, 699 

serous, 699 
Lichen, 93 

Ligamentum patellae, rupture of, 599 
Linea alba, hernia through, 461 
Lingual goitre, 295 
Lipoma of abdominal wall, 488 

of arm, 447 

of axilla, 448 

of bone, 128 

of brain, 168 

of conjunctiva, 263 

of face, 251 

of foot, 579 

of forearm, 384 

of hand, 365 

of intestines, 537 

of joints, 139 

of lips, 281 

of muscles, 110 

of neck, 315, 316, 320 

of popliteal space, 613 



756 



INDEX 



Lipoma, postperitoneal, 492 

of salivary glands, 304 

of scalp, 240 

of scrotum, 652 

of shoulder, 448 

of spermatic cord, 660 

of tendons, 115 

of thigh, 618 

of thorax, 460 

of tongue, 295 

of umbilicus, 489 

of vulva, 712 
Lips, adenoma of, 281 

angioma of, 280 

chancre of, 279 

cysts of, 281 

epithelioma of, 280 

gumma of, 280 

herpes of, 279 

inflammations of, 279 

lipoma of, 281 

mucous patches of, 279 

tumors of, 280 
mixed, 281 

ulcerations of, 279 
Littre's hernia, 507 
Liver, abscess of, 495, 520 

angioma of, 519 

carcinoma of, 495, 519 

corset, 518 

cysts of, 495, 519 

diseases of, x-rays in, 64 

enlargement of, 518 

floating, 494 

gumma of, 495, 519 

l3rmphangioma of, 519 

malformations of, 518 

movable, 518 

sarcoma of, 519 

spots, 94 

syphilis of, 519 

transposition of, 518 

trauma of, 518 

tuberculosis of, 519 

timiors of, 493, 519 
Locomotor ataxia, 197 
Loose bodies in joints, :r-rays in diagnosis 

of, 53 
Lordosis, 336 
Lumbar hernia, 506 

nerves, diseases of, 222 
Lungs, abscess of, 459 

a:-rays in diagnosis of, 61 

actinomycosis of, 459 

echinococcus cysts of, 459 

gangrene of, 459 

rc-rays in diagnosis of, 61 

syphilis of, 459 

tuberculosis of, 459 

tumor of, 462 

wounds of, 453 
Lupus erythematosis, 94 

of foot, 563 

of larynx, 324 

vulgaris, 94 

of vulva, 712 



Luxation. See Dislocations. 
Lymph glands, actinomycosis of, 305 
inflammation of, 303 
sarcoma of, 303 
tuberculosis of, 305 
Lymphadenitis, 103 

acute, 246 

tuberculous, 312 
Lymphangiectasis, 102 
Lymphangioma of axilla, 448 

of face, 252 

of liver, 519 

of muscles, 110 

of neck, 102 

of penis, 647 

of scrotum, 651 
Lymphangitis, 101 

acute, 101 

chronic, 102 

of forearm, 382 

malignant, 102 

of penis, 641 

tuberculous, 102 
Lymphatic leukemia, 21, 106, 313 
Lymphedema, 103 

of foot, 562 

of scrotum, 652 
Lymphoma, malignant, of neck, 313 

of orbit, 265 
Lymphosarcoma, 106 

of neck, 313 



M 



Macrocheilia, 102 
Macroglossia, 102 

congenital, 294 
Madura foot, 563 
Malar bone, fracture of, 245 
Malformations of anus, 545 

of bladder, 671 

of breast, 464 

of cervix, 715 

of ear, 254 

of elbow, 389 

of esophagus, congenital, 472 

of face, 244 

of Fallopian tubes, 726 

of forearm, 370 

of hand, 346 

of hip, 621 

of liver, 518 

of neck, congenital, 306 

of ovaries, 726 

of penis, 640 

of rectum, 545 

of seminal vesicles, 660 

of thorax, 451 

of tongue, 292 

of urethra, 666 

of uterus, 720 

of vagina, 713 

of vulva, 707 
Malleolus, fracture of, 569 
Malposition of bladder, 671 



INDEX 



757 



Mastitis, 467 

syphilitic, 468 
tuberculous, 468 
Mastodynia, 470 
Mastoiditis, 258 

Maxillary sinus, carcinoma of, 276 
enchondroma of, 276 
fibroma of, 276 
inflammation of, 275 
mucous cysts of, 276 
myoma of, 276 
osteoma of, 276 
sarcoma of, 276 
tumors of, 276 
Median nerve, paralysis of, 221 
Mediastinum, inflammation of, 456 

tumor of, 462 
Medulla oblongata, 147 
tumors of, 178 
Meniere's disease, 152 
Meninges of brain, diseases of, 201 

of spinal cord, diseases of, 201 
Meningism, 203 
Meningitis, cerebrospinal, 202 
purulent, 202 
serous, 203, 204 
syphilitic, 166 
tuberculous, 202, 235 
in infants, 203 
Meningocele, 243, 334 

of orbit, 266 
Meningomyelocele, 334 
Menorrhagia, 698 

Menstrual flow, suppression of, 698 
Menstruation, scanty, 698 
Mercurial poisoning, 81 

stomatitis, 288 
Mesentery, cysts of, 493 
Metacarpal bones, fracture of, 353 

tuberculosis of, 367 
Metatarsal joints, arthritis of, 576 
Metatarsalgia, anterior, 561 
Metatarsophalangeal joints, arthritis of, 

576 
Metritis, acute, 722 

chronic, 722 
Metrorrhagia, 698 
Microcephalus, 244 
Mikulicz's disease, 303 
Miliaria, 91 
Milium of eyelids, 260 
MoUuscum contagiosum, 93 
of eyelids, 260 
of scrotum, 650 
Motor aphasia, 142 

centres of brain, 142 

tumors of, 174 
functions of spinal cord, 191 
Mouth, epithelioma of, 289 
inflammations of, 288 
mucous patches of, 288 
Movable kidney, 496, 497, 683 

liver, 518 
Mucous patches of lips, 279 
of mouth, 288 
of tongue, 293 



Mumps, 301 

Muscles, abdominal, rupture of, 488 

angioma of, 110 

of arm, rupture of, 418 

atrophy of, 111 

contracture of. 111 

contusions of, 107 

echinococcus cyst of, 110 

enchondroma of, 110 

of eye, paralysis of, 268 3 

of forearm, rupture of, 371 

gumma of, 1 10 

hernia of, 108 

inflammation of, 108 

lipoma of, 110 

lymphangioma of, 110 

neoplasms of, 110 

paralysis of, 110 

postanesthetic. 111 

rupture of, 107 

x-rays in diagnosis of, 67 

sarcoma of, 110 

syphilis of, 109 

of thigh, hernia of, 615 
rupture of, 615 

traumatisms of, 107 

tuberculosis of, 109 
Musculospiral nerve, paralysis of, 221 
Mycetoma, 563 
Myehtis, 198, 199 
Myelogenous leukemia, 21 
Myeloma of bone, 129 

of spine, 343 
Myoma of intestines, 537 

of maxillary sinus, 276 
Myositis, 108 

chronic, 109 

diffuse phlegmonous, 108 

infectious, 108 

ossifying, 109 

suppurative, 108 

syphilitic, 109 

toxic, 108 

traumatic, 108 

tuberculous, 109 

a;-rays in diagnosis of, 66 
Myxedema, 326 
Myxoma of bursa, 117 

of umbilicus, 489 



N 

Nasal calculi, 273 

duct, stricture of, 261 
Nasoliths, 274 

Nasopharyngeal fibroma, 278 
Nasopharynx, angioma of, 279 

chondroma of, 279 

inflammation of, 278 

tumors of, 278 
Neck, actinomj^cosis of, 315 

adenopathy of, 316 

aneurysm of, 320 

arteriovenous, 321 

carcinoma of, 314 



758 



INDEX 



Neck, congenital malformations of, 306 

tumors of, 307 
contusions of, 308 
cysts of, 317, 318, 319 
fibroma of, 317 

glands of, inflammation of, 319 
inflammations of, 310 
inflammatory hyperplasia of, 312 
lipoma of, 315, 316, 320 
lymphangioma of, 102 
lymphoma of, 313 
lymphosarcoma of, 313 
sarcoma of, 320 
teratoma of, 307 
traumatisms of, 308 
tumors of, 312 
vascular goitre of, 315 
wounds of, vascular, 309 
wry-, 218 
Neoplasms of kidney, 496 
Nephritis, acute hematogenous, 689 
Nephroptosis, a;-rays in diagnosis of, 63 
Nerves, abducens, functions of, 152 

paralysis of, 152 
auditory, functions of, 152 
cervical, diseases of, 219 
circumflex, paralysis of, 221 
cranial, diseases of, 215 
eighth, functions of, 152 
eleventh, functions of, 153 
external popliteal, paralysis of, 222 
facial, functions of, 152 

paralysis of, 152 
fibroma of, 222 
fifth, functions of, 152 

paralysis of, 152 
fourth, paralysis of, 152 
glossopharyngeal, functions of, 152 
hypoglossal, functions of, 153 
lumbar, diseases of, 222 
median, paralysis of, 221 
musculospiral, paralysis of, 221 
neuroma of, 222 
ninth, functions of, 152 
oculomotor, functions of, 151 
olfactory, functions of, 148 
optic, functions of, 149 
peripheral, diseases of, 214 
pneumogastric, functions of, 153 
recurrent laryngeal, paralysis of, 325 
sacral, diseases of, 222 
second, functions of, 149 
seventh, functions of, 152 

paralysis of, 152 
sixth, functions of, 152 

paralysis of, 152 
spinal accessory, functions of, 153 
tenth, functions of, 153 
third, functions of, 151 
thoracic, diseases of, 222 

paralysis of, 221 
trigeminus, functions of, 152 

paralysis of, 152 
trochlear, paralysis of, 152 
tumors of, 222 
twelfth, functions of, 153 



Nerves, ulnar, paralysis of, 221 
Nervous system, diseases of, 140 
Neuralgia, brachial, 220 

cervical, 219 

facial, 253 

infra-orbital, 215 

of knee-joint, 613 

occipital, 219 

supra-orbital, 215 

of testicle, 658 
Neurasthenia, traumatic, 211 
Neuritis, brachial, 219 

optic, 151 
Neurofibroma of forearm, 384 

of scalp, 239 
Neuroma of nerves, 222 

of orbit, 265 

plexiform, of eyelids, 260 
Neuropathic arthritis, 138 
of elbow, 416 
of knee-joint, 613 
of shoulder, 447 
Neurosis of joints, 139, 447 

traumatic, 211 
Neurotic spine, 336 
Nevus, 99 

Ninth nerve, functions of, 152 
Nipple, chancre of, 466 

eczema of, 466 

epithelioma of, 466 

fissure of, 466 

Paget's disease of, 466 
Noguchi reaction in diagnosis of syphilis, 

35 
Noma, 246, 289 
Nose, acne rosacea of, 273 

chancre of, 273 

congenital deformities of, 272 

contusion of, 272 

diseases of, a;-rays in diagnosis of, 54 

eczema of, 273 

elephantiasis of, 273 

epithelioma of, 275 

erysipelas of, 272 

erythema of, 273 

foreign bodies in, 273 

fracture of, 272 

furuncle of, 272 

gumma of, 274 

hemorrhage of, 271 

inflammation of, 273 

osteoma of, 275 

polypi of, 275 

sarcoma of, 275 

syphilis of, 274 

traumatism of, 272 

tuberculosis of, 274 

tumors of, 275 

ulcerations of, 273 
Nucleo-albumin in urine, 25 



Obstetric palsy. 111 
Obturation ileus, 481 



INDEX 



759 



Obturator hernia, 506, 638 
Occipital lobe, tumors of, 176 

neuralgia, 219 
Occupation paresis, 348 

spasm, 348 
Oculomotor nerve, functions of, 151 
Odontoma of jaw, 285 
Olecranon, fractures of, 405 
Olfactory nerve, functions of, 148 
Omental hernia, 500 
Omentum, cysts of, 493 

hematoma of, 493 

torsion of, 493 
Operations, sudden death after, 80 
Ophthalmia, gonorrheal, 262 

neonatorum, 262 
Ophthalmoplegia, 270 
Optic nerve, functions of, 149 

neuritis, 151 
Orbit, angioma of, 264 

carcinoma of, 265 

contusions of, 263 

cysts of, 265, 266 

encephalocele of, 266 

exostoses of, 264 

foreign bodies in, a;-rays in diagnosis 
of, 54 

fracture of, 264 

inflammation of, 264 

lymphoma of, 265 

meningocele of, 266 

osteoma of, 264 

plexiform neuroma of, 265 

sarcoma of, 265 

teratoma of, 266 

tumors of, 264, 265 
Os magnum, dislocation of, 358 
Ossifying myositis, 109 
Osteitis deformans, 127, 343 

rc-rays in diagnosis of, 42 

gummatous, of clavicle, 446 
of humerus, 446 

post-typhoidal, a:-rays in diagnosis 
of, 42 

syphilitic, of scapula, 446 

tuberculous, of scapula, 446 
Osteoarthritis of knee, 599 
Osteo-arthropathy of hand, 348 
Osteogenesis imperfecta, 127 
Osteoma of bone, 127 

of brain, 168 

of jaw, 285 

of maxillary sinus, 276 

of nose, 275 

of orbit, 264 

of ribs, 461 

rider's, 109 

of skull, 242 

of sternum, 461 

a;-rays in diagnosis of, 45 
Osteomalacia, 126 

Osteomyelitis, acute, of humerus, 440 
infective, 121 
of jaw, 284 
of ribs, 455 
of spine, 340 



Osteomyelitis, acute, of sternum, 455 

suppurating, 234 

of tibia, 588 

a:-rays in diagnosis of, 39 
chronic, 125 

of hmnerus, 445 

infective, 123 

of ribs, 455 

of sternum, 455 

traumatic, 122 

rc-rays in diagnosis of, 39 
of femur, shaft, 617 
fever of, 73 
of forearm, 383 
of hip, 629 
of pelvis, 635 
syphilitic, 124 

of ribs, 455 

of sternum, 455 
tuberculous, 123 

of ribs, 456 

of sternum, 456 
typhoidal, of ribs, 455 

of sternmn, 455 
Osteoperiostitis, acute infective, 121 

of jaw, 284 

suppurative, 121 

syphiUtic, 121, 123 

traumatic, 120 
chronic rheimiatic, 123 
gonorrheal, 121, 123 
of tibia, acute traumatic, 587 

gummatous, 588 

syphilitic, 588 

tvphoid, 588 
typhoid, 121 
rc-rays in diagnosis of, 56 
Osteosarcoma of brain, 164 

x-rays in diagnosis of, 44 
Otitis media, acute, 256 

chronic suppurative, 257 
fever of, 73 
Ovaries, abscess of, 727 

c,ystic degeneration of, 731 
cysts of, dermoid, 734 

glandular, 732 

papillomatous, 734 
inflammation of, 727 
malformations of, 726 
prolapse of, 731 
rudimentary, 726 
tumors of, 732, 734 



Pachymeningitis, cerebral, 201 

spinal, 201 
Paget's disease of bone, 127 

of nipple, 466 
Painful foot, 560 

heel, 561 

stumps, .T-rays in diagnosis of, 67 
Palate, abscess of, 299 

cysts of, 299 

gumma of, 299 



ii 



760 



INDEX 



Palate, syphilis of, 299 
. tuberculosis of, 299 

tumors of, 299 
Palmar abscess, 360 

keratitis, 360 
Palsy, Bell's, 216 

brachial, 220 

crutch. 111 

facial, 216 

infantile, 194 

median nerve, 221 

musculospiral, 221 

obstetric. 111 

pressure, 79 

reflex, 111 

ulnar nerve, 221 
Pancreas, abscess of, 526 

calculi of, 527 

carcinoma of, 527 

cysts of, 527 

diseases of, x-rays in diagnosis of, 64 

inflammation of, 525 

injuries of, 525 

tumors of, 527 
Pancreatitis, 525, 526 
Papilloma of anus, 549 

of esophagus, 474 

of eyelids, 260 

of kidney, 691 

of larynx, 325 

of penis, 646 
Papillomatous cysts of ovary, 734 
Paralysis of abducens nerve, 152 

of brachial plexus, 220 

Brown-Sequard, 200 

of circumflex nerves, 221 

in diseases of brain, 155 

Duchenne-Erb, 220 

of external popliteal nerve, 222 

of facial nerve, 152 

of fifth nerve, 152 

of fourth nerve, 152 

of median nerve, 221 

of muscles. 111 
of eye, 268 

of musculospiral nerve, 221 

of recurrent laryngeal nerve, 325 

of seventh nerve, 152 

of sixth nerve, 152 

of thoracic nerves, 221 

of trigeminus nerve, 152 

of trochlear nerve, 152 

of ulnar nerve, 221 
Paraphimosis, 642 
Parasitic sycosis, 87 
Parathyroid glands, 326 
Parenchymatous goitre, 328 
Paresis, occupation, 348 
Paronychia, 359 , 
Parotid gland, calculus of, 301 
foreign bodies in, 302 
gumma of, 305 
inflammation of, 302 
sarcoma of, 304, 305 
syphilis of, 302 
tumors of, 301 



Parotiditis, 302 
Parotitis, postoperative, 80 
Parovarian cysts, 734 
Patella, fracture of, 600 
Patellar clonus, 156 

jerk, 156 
Pediculi, 89 

Pediculosis of scrotum, 650 
Peduncles, cerebral, 145 
Pelvic examination, 703 

floor, relaxation of, 714 

peritonitis, acute, 727 
chronic, 729 
gonorrheal, 728 

diagnosis of, from appen- 
dicitis, 728 
instrumental, 729 
postoperative, 729 
puerperal, 728 
Pelvis, foreign bodies in, a:-rays in diag- 
nosis, 64 

fractures of, 635 

osteomyelitis of, 635 

sarcoma of, 639 
Penis, abrasions of, 643 

abscess of, 646 

balanoposthitis of, 642 

cavernitis of, 641 

cellulitis of, 641 

chancre of, 643 

chancroid of, 645 

congenital malformations of, 640 

contusion of, 640 

cracks of, 643 

dermatitis of, 641 

dermoid cysts of, 648 

dislocation of, 640 

eczema of, 641 

elephantiasis of, 647 

epithelioma of, 647 

erysipelas of, 641 

erythema intertrigo of, 641 

fissures of, 643 

fracture of, 640 

functional disturbances of, 648 

herpes of, 643 

inflammations of, 641 

lymphangioma of, 647 

lymphangitis of, 641 

papilloma of, 646 

paraphimosis of, 642 

phlebitis of, 641 

pruritus of, 641 

sarcoma of, 647 

syphilis of, 645 

trauma of, 640 

tuberculosis of, 646 

tumors of, 646 

ulcers of, 646 

urticaria of, 641 

wounds of, 640 
Peptones in urine, 25 
Perforating ulcers of foot, 563 
Perianal region, syphilis of, 549 
Periarthritis, acute gouty, of hand, 366 
of wrist, 366 



INDEX 



761 



Periarticular inflammation, 606 
Pericarditis, 457 
Pericardium, adherent, 457 

inflammation of, 457 
Perichondritis, 323 
Perigastric adhesions, 513 
Perineal hernia, 507 
Perinephric abscess, 497 

x-T&ys in diagnosis of, 63 

suppuration, 689 
Perineum, tears of, 714 
Periosteitis, acute suppurative, a:-rays in 

diagnosis of, 39 
Peripheral nerves, diseases of, 214 
Perirectal tumor, 555 
Peritendinous cellulitis, 112 
Peritoneal effusion, diffuse, 490 
Peritoneum, actinom5^cosis of, 480 

carcinoma of, 481 

inflammation of, 477 

tuberculosis of, 480 
Peritonitis, 477 

acute, 478 

chronic, 480 

pehic, acute, 727 
chronic, 729 
gonorrheal, 728 

diagnosis of, from appendi- 
citis, 728 
instrumental, 729 
postoperative, 729 
puerperal, 728 

tuberculous, 480 
Peritonsillar abscess, 296 
Periurethral abscess, 668 
Pes planus, 560 
Phagedenic adenitis, 105 
Phalanges, tuberculosis of, 367 
Phantom tumor, 489 
Pharyngeal diverticulum, 298 
Pharynx, foreign bodies in, 298 

gumma of, 299 

inflammation of, 298 
Phlebitis, 96 

of penis, 641 

postoperative, 80 
Phlegmonous myositis, diffuse, 108 
Phlyctenular conjunctivitis, 263 

keratitis, 266 
Physometra of uterus, 726 
Pia arachnoid, inflammation of, 202 
Pitvriasis rosea, 93 
Plastic iritis, 267 
Pleura, timior of, 462 
Pleural effusions, 457 

a;-rays in diagnosis of, 62 
Plexiform neuroma of eyelids, 260 

of orbit, 265 
Pneumocele of scalp, 243 
Pneumococci in sputirai, 32 
Pneumococcic arthritis, 135, 629 

urethritis, 669 
Pneumogastric nerve, functions of, 153 
Pneumonia, postoperative, 80 

a;-rays in diagnosis of, 61 
Poisoning, iodoform, 81 



Poisoning, mercurial, 81 
Poliomyelitis, acute anterior, 194 

chronic, 195 
Polycystic disease, 497 
Polymastia, 464 
Polyps, cervical, 717 

of conjunctiva, 263 

of ear, 256 

of esophagus, 475 

of nose, 275 

of rectimi, 554 

of t3"mpanum, 257 

urethral, 670 
Polythelia, 464 
Pons, 147 

tumors of, 178 
Popliteal artery, aneurysm of, 609 

bursitis, 608 

nerve, external, paralysis of, 222 

space, inflammation of, 606 
lipoma of, 613 
Postanesthetic paralysis of muscles. 111 
Posterolateral sclerosis, 198 
Postoperative complications of celiotomv, 
79 

tetany, 327 

vomiting, 78 
Postperitoneal lipoma, 492 
Post-traumatic arthritis, acute, of wrist, 
366 
of joints of ankle, 577 
Post-typhoidal osteitis, .r-rays in diagno- 
sis of, 42 
Pott's fracture, 568 
Pregnane}^, tubal, 730 
Prepatellar bursitis, 607, 698 
Pressure palsies, 79 
Pretibial bursitis, 607 
Prickly heat, 91 
Proctitis, acute catarrhal, 550 

chronic, 550 

diphtheritic, 550 

d5'senteric, 550 

gonorrheal, 550 
Prolapse of anus, 551 

of ovary, 731 

of uterus, 720 
Prostate, calculi of, 663 

x-rays in diagnosis of, 63 

enlargement of, 663 

inflammation of, 662 

tumors of, 664 
Prostatitis, acute, 662 

chronic, 663 
Pruritus of anus, 546 

of penis, 641 

of scrotum, 650 

vulvse, 708 
Psammoma of brain, 168 
Pseudomeningitis, 203 
Psoas abscess, 497, 615 
Psoriasis, 86, 310 
Psychical centres of brain, 144 

epilepsy, 155 
Pubic symphysis, disjunction of, 634 
Puerperal pelvic peritonitis, 728 



762 



INDEX 



Pulmonary osteoarthropathy of hand, 348 

Purpura, 93 

Purulent arthritis of infants, 136 

meningitis, 202 
Pyelitis, 687 
Pyelonephritis, 496, 688 
Pyemia, 73 
Pylorus, hypertrophic stenosis of, 512 

obstruction of, 512 

tumors of, 493 
Pyometra of uterus, 726 
Pyonephrosis, 688 

oj-rays in diagnosis of, 63 
Pyorrhea alveolaris, 291 
Pyosalpinx, 727 
Pyuria, 671 



Q 



Quadriceps tendon, rupture of, 599 



Radial styloid, dislocation of, 358 
Radiocarpal dislocations, 357 
Radio-ulnar dislocations, 358 
Radius, dislocations of, 412 

fractures of, 380 
head, 405 
lower extremity, 355 

fissured, 357 
neck, 405 

subluxation of, 413 
Ranula, 295 
Raynaud's disease, 365 
Recklinghausen's disease, 222 
Rectal centres of spinal cord, 193 
Rectocele, 715 

Rectovaginal fistula, 714, 735 
Rectum, carcinoma of, 555 

congenital malformations of, 545 

foreign bodies in, 552 

polyp of, 554 

sarcoma of, 555 

stricture of, 553, 554 

trauma of, 552 

tumors of, 554 

ulcers of, 552, 553 
Reflex palsies, 112 
Reflexes, 155 

abdominal, 157 

Babinski's, 157 

biceps, 156 

cremasteric, 157 

plantar, 157 

skin, 157 

superficial, 157 

triceps, 156 

umbilical, 157 
Renal artery, aneurysm of, 691 

calculi, 684 

a;-rays in diagnosis of, 62 

hematuria, 26 

tumors, 496 



Reproductive organs, anatomy of, 693 
examination of, 700 

abdominal, position for, 702 
armamentarium for, 703 
position of patient in, 701 
preparation of patient for, 
702 
Retention of testicle, abdominal, 651 
cruroscrotal, 651 
inguinal, 651 
Retrocalcaneal bursitis, 574 
Retroperitoneal cysts, 492 

swellings, 491 
Retropharyngeal abscess, 298 
Retroposition of uterus, 720 
Rheumatic arthritis, 134 
of elbow, 415 
of hip, 628 
of knee-joint, 610 
of temporomaxillary articula- 
tion, 287 
osteoperiostitis, 123 
Rheumatism of sacro-iliac joint, 636 
Rheumatoid arthritis, 343, 366 
Rhinitis, acute, 273 
atrophic, 274 
chronic, 274 
diphtheritic, 273 
hypertrophic, 274 
Ribs, cervical, 308, 335 

rr-rays in diagnosis of, 54 
chondroma of, 461 
deformities of, x-rays in diagnosis of, 

57 
fracture of, 454 

x-rays in diagnosis of, 56 
gumma of, 456 
osteoma of, 461 
osteomyelitis of, 455, 456 
sarcoma of, 461 
tumors of, 461 

x-rays in diagnosis of, 57 
Richter's hernia, 507 
Rickets, 126 

x-rays in diagnosis of, 43 
Rider's osteoma, 109 
Riedel's lobe, 494 
Ringworm, 87 

Round ligament, hydrocele of, 638 
Rudimentary ovary, 726 
Rupture of bladder, 674 
of bloodvessels, 96 
of crucial ligaments, 599 
of esophagus, 472 
of ligamentum patellae, 599 
of muscles, 107 

of abdomen, 488 
of arm, 418 
of forearm, 371 
of thigh, 615 
x-rays in diagnosis of, 67 
of quadriceps tendon, 599 
of semilunar cartilage, 599 
of spleen, 530 
of stomach, 510 
of tendons, 112 



INDEX 



763 



Rupture of tendons of foot, 574 
of forearm, 371 
of thoracic duct, 101 
of ureter, 680 
of urethra, traumatic, 666 



Sacral nerves, diseases of, 222 
Sacrococcygeal tumors, congenital, 633 
Sacro-iliac joint, chondroma of, 637 

exostoses of, 637 

gonorrhea of, 637 

inflammation of, 636 

rheumatism of, 637 

sarcoma of, 637 

strain of, 635 

syphilis of, 637 

tuberculosis of, 636 

tumors of, 637 
Sacrum, cysts of, 334 

tumors of, 334 
Salivary calculi, 291 

a:-ra3^s in diagnosis of, 55 
glands, carcinoma of, 305 

chondroma of, 304 

cysts of, 304 

diseases of, 300 

enlargement of, 303 

fibroma of, 304 

fistula of, 305 

lipoma of, 304 

tumors of, 304 
Salpingitis, acute, 727 

chronic, 729 
Sarcoma of abdominal wall, 489 
of arm, 447 
of axilla, 448 
of bone, 129 

a:-rays in diagnosis of, 41, 43 
of brain, 164 
of bursa, 117 
of buttocks, 633 
of cervix, 719 
of eyelids, 260 
of face, 252 
of foot, 563, 579 
of forearm, 384 
of hand, 369 
of humerus, 448 
of intestines, 537 
of jaw, 285 
of larynx, 325 
of liver, 519 
of Ij^mph glands, 303 
of maxillar}^ sinus, 276 
of muscles, 110 
of neck, 320 
of nose, 275 
of orbit, 265 

of parotid gland, 304, 305 
of pelvis, 639 
of penis, 647 
of rectum, 555 
of ribs, 461 



Sarcoma of sacro-iliac joint, 637 

of scalp, 242 

of skin, 95 

of skull, 242 

of spinal cord, 206 

of spine, 343 

of spleen, 499, 531 

of sternum, 461 

of thigh, 618 

of thorax, 460 

of thymus gland, 331 

of thyroid gland, 329 

of tibia, 595, 614 

of tongue, 295 

of tonsils, 297 

of umbilicus, 489 

of uterus, 723 

of vagina, 714 

of vulva, 712 
Scalds of larynx, 323 
Scalp, aneur3'sm of, 238, 239 

angioma of, 238 

carcinoma of, 241 

contusions of, 223 

C3^sts of, sebaceous, 240 

elephantiasis of, 239 

epithelioma of, 241 

er3^sipelas of, 233 

fibrol3niiphangioma of, 239 

fibroma of, 239 

fm-uncles of, 233 

gumma of, 234 

inflammations of, 232 

lipoma of, 240 

neurofibroma of, 239 

pneumocele of, 243 

sarcoma of, 242 

seborrhea of, 232 

S3^philis of, 233 

tuberculosis of, 233 

tumors of, 238 

verruca of, 238 

warts of, 238 

wens of, 240 
Scaphoid, tarsal, fracture of, 565 
Scapula, fractures of, 430 

acromion process, 433 
coracoid process, 433 
neck of, 433 

S3^philitic osteitis of, 446 

tuberculous osteitis of, 446 
Scarlet fever arthritis, 135 
Sciatic hernia, 506 
Sciatica, 222, 616 
Sclerosing gastritis, 515 
Sclerosis of internal vesical sphincter, 664 

lateral, 197 

amyotrophic, 197 

posterolateral, 198 
Scoliosis, a:-rays in diagnosis of, 54, 58 
Scrotum, abscess of, 650 

cellulitis of, 651 

contusions of, 649 

eczema of, 649 

edema of, 649 

emphysema of, 649 



764 



INDEX 



Scrotum, epithelioma of, 651 
erosions of, 649 
erythema intertrigo of, 649 
lipoma of, 651 
lymphangioma of, 651 
lymphedema of, 651 
moUuscum contagiosum of, 650 
pediculosis of, 650 
pruritus of, 650 
sebaceous cysts of, 650 
tumors of, 651 
ulcers of, 649 
Sebaceous cysts of breast, 468 
of face, 252 
of neck, 319 
of scalp, 240 
of scrotum, 650 
Seborrhea, 91 

of scalp, 232 
Second nerve, functions of, 149 
Secretions, examination of, 34, 35 
Semilunar bone, dislocation of, 358 
cartilage, rupture of, 599 
subluxation of, 598 
Seminal vesicles, cysts of, 661 
inflammation of, 660 
malformations of, 660 
malignant infiltration of, 662 
Senile gangrene, 100 

of hand, 365 
Sensory aphasia, 144 

centres of brain, 142 

tumors of, 175 
functions of spinal cord, 193 
Septicemia, 70 
Serous meningitis, 203, 204 
Seventh nerve, functions of, 152 

paralysis of, 152 
Sexual centres of spinal cord, 193 
Shock, 78 

Shoulder, arthritis of, acute serous, 440 
suppurative, 440 
chronic, 446 
fungous, 447 
neuropathic, 447 
serofibrinous, 440 
tuberculous, 447 
bones of, inflammations of, 445 
bursa of, inflammation of, 442 
contusions of, 418 
inflammations of, 438, 441 
joints of, dislocations of, 435 
inflammations of, 445 
neuroses of, 447 
ic-rays in diagnosis of, 47 
lipoma of, 448 

nerves of, inflammation of, 442 
sprains of, 418 
traumatisms of, 418 
tumors of, 447 
Sigmoid, diseases of, a:-rays in, 66 
Sixth nerve, functions of, 152 

paralysis of, 152 
Skin, epithelioma of, 95 

erythematous lesions of, 91 
hemorrhages of, 93 



Skin, hypertrophies of, 93 
inflammations of, 84 
lesions of face, 245 
sarcoma of, 95 
syphilitic lesions of, 85 
tabs, 307 

inflamed, 546 
tuberculosis of, 94 
Skull, anterior fossa of, fracture of, 228 
chondroma of, 242 
cysts of, dermoid, 243 
fracture of base of, 186, 223 
inflammations of, 232 
middle fossa of, fracture of, 229 
osteoma of, 242 

posterior fossa of, fracture of, 230 
sarcoma of, 242 
tumors of, 238 

x-Tays in diagnosis of, 55 
wounds of, 231 
gunshot, 232 
penetrating, 231 
Spasm, facial, 216 

occupation, 348 
Spermatic cord, hydrocele of, 638 

lipoma of, 660 
Sphenoidal sinus, inflammation of, 277 
Spina bifida, 211, 334 
occulta, 334 
ventosa, 367 
Spinal accessory nerve, function of, 153 
column, 332. See also Vertebra and 
spine, 
arthritis of, rc-rays in diagnosis 

of, 58 
anomalies of, 334 
general symptomatology of af- 
fection of, 333 
cord, anatomical relations of, 187 
anterior horn of, diseases of, 194 
centres of, bladder, 193 
rectal, 193 
sexual, 193 
cysts of, 206 
fibroma of, 206 
functions of, 190 
motor, 191 
sensory, 193 
inflammation of, 198 
injuries of, 207, 208 
lateral columns of, diseases of, 

197 
localization of, 190 
meninges of, diseases of, 201 
motor columns of, diseases of, 

197 
posterior columns of, diseases of, 

197 
roots of, 188 

anterior, lesions of, 200 
posterior, lesions of, 200 
sarcoma of, 206 
segments of, 190 
tumors of, 205 
unilateral lesions of, 200 
fluid, examination of, 35 



INDEX 



765 



Spinal pachymeningitis, 201 
Spine, actinomycosis of, 343 

acute osteomyelitis of, 340 

carcinoma of, 343 

contusions of, 336 

curvature of, 335 

dislocations of, 336 

unaccompanied by fracture, 338 

exostoses of, 343 

fracture dislocations of, 339 

fractures of, 336 

unaccompanied by dislocation, 
339 

inflammation of, 340 

lumbar, diseases of, .T-rays in diag- 
nosis of, 65 

myeloma of, 343 

neurotic, 336 

sarcoma of, 343 

sprain of, 336 

syphilis of, 343 

trauma of, 336 

tuberculosis of, 340 

tumors of, 343 

typhoid, 342 

wounds of, 340 
Spirocheta pallida, 36 
Spleen, abscess of, 499 

acute suppurative infection of, 530 

anomalies of, 529 

carcinoma of, 531 

congestion of, 530 

cysts of, 531 

degeneration of, 531 

diseases of, rc-rays in diagnosis of, 64 

enlargement of, 499 

floating, 499 

hypertrophy of, 530 

inflammations of, 530 

leukemic enlargement of, 531 

rupture of, 530 

sarcoma of, 499, 531 

syphilis of, 531 

traumatism of, 530 

tuberculosis of, 531 

tumors of, 531 

wounds of, 530 
Splenic anemia, 531 
Splenitis, 530 
Spondylitis, acute suppurative, 340 

chronic traumatic, 342 

deformans, 343 

gonorrheal, 342 

S3^hilitic, 343 

tuberculous, 340 

typhoidal, 342 
Sprains of ankle, 564 

of elbow, 393 

of foot, 564 

of joints, 131 

of knee, 598 

of shoulder, 418 

of spine, 336 

of temporomaxillarv articulation, 
287 

of vertebra, 207 , 



Sputum, examination of, 31 

pneumococcus in, 32 

tubercle bacilli in, 32 
Stenosis of larynx, 324 

of pylorus, hj^pertrophic, 512 

of trachea, 324 
Sterility, 700 

developmental, 700 

functional, 700 

inflammator}^ diseases and, 700 

mechanical impediments and, 700 
Sternum, chondroma of, 461 

diseases of, a:-rays in diagnosis of, 57 

dislocation of, a:-ra3's in diagnosis of, 
57 

fracture of, 454 

.T-rays in diagnosis of, 57 

gumma of, 456 

osteoma of, 461 

osteomj^elitis of, 455, 456 

tumors of, 461 

a;-rays in diagnosis of, 57 
Still's disease, 135 
Stomach, abscess of, 493 

carcinoma of, 514 

contusions of, 510 

dilatation of, acute, 511 

diseases of, a:-rays in diagnosis of, 65 

foreign bodies in, 511 

hourglass, 515 

inflammations of, 485, 515 

rupture of, 510 

trauma of, 510 

tumors of, 493, 514 

ulcer of, 513 

volvulus of, 513 

wounds of, 511 
Stomatitis, 288 

gangrenous, 289 

mercurial, 288 

ulceromembranous, 289 
Strain of sacro-iliac joint, 635 
Strangulated hernia, 501 
Strangulation ileus, 482 
Stricture of esophagus, 474 

of nasal duct, 261 

of rectum, 553, 554 

of ureter, 680 
Stye, 259 

Subastragaloid dislocations, 571 
Subclavian artery, aneurysm of, 321 
Subcoracoid bursitis, 442 
Subcortical centres of brain, 145 

tumors of, 178 
Subdeltoideian bursa, inflammation of, 
acute suppurative, 439 

bursitis, 442 
Subhj^oid bursa, 319 
Sublingual abscess, 310 

gland, diseases of, 301 
Subluxation of radius, 413 

of semilunar cartilage, 598 

of wrist, 358 
Submammar}^ abscess, 466 
Submaxillary adenitis, 310 

gland, diseases of, 300 



766 



INDEX 



Submaxillary gland, foreign bodies in, 
306 
tumors of, 306 
Submental adenitis, 310 
Subphrenic abscess, 495, 499 

a;-rays in diagnosis of, 62 
Suburethral abscess, 736 
Suppuration, perinephric, 689 
Suppurative arthritis of elbow, 415 

catarrhal pancreatitis, 526 

disease of kidney, 687 

myositis, 108 

osteoperiostitis, 121 
Supracondyloid fracture, 396 
Suprahyoid bursa, 319 
Supramalleolar fractures, 569 
Supramammary abscess, 466 
Supra-orbital neuralgia, 215 
Suprarenal bodies, tumors of, 497 

gland, cysts of, 692 
tumors of, 692 

tumors, 496 
Sycosis, 92 

parasitic, 87 
Symmetrical gangrene of hand, 365 
Synovitis, fungous, 114 
Syphilis of abdominal wall, 488 

of arms, 549 

of biceps muscle, 441 

of bones, 121, 123, 124 

hereditary, a;-rays in diagnosis 

of, 42 
a:-rays in diagnosis of, 40 

of brain, 166 

of breast, 468 

of bursa, 116 

of esophagus, 474 

of face, 248 

of forearm, 383 

of hand, 362, 367 

of intestines, 536 

of jaw, 284 

of joints, 138 

of kidneys, 691 

of larynx, 324 

of liver, 519 

of lung, 459 

of muscles, 109 

Noguchi reaction in, 35 

of nose, 274 

of palate, 299 

of parotid gland, 302 

of penis, 645 

of perianal region, 549 

of sacro-iliac joint, 637 

of scalp, 233 

of spine, 343 

of spleen, 531 

of tendons, 112 

of testicle, 658 

of tongue, 293 

of tonsils, 297 

of vertebrae, 343 

of vulva, 709 

Wasserman reaction in, 35 
Syphilitic adenitis, 104 



Syphilitic adenopathy of neck, 316 

arthritis of elbow, 415 
of knee-joint, 612 

dactylitis, x-rays in diagnosis of, 42 

lesions of skin, 85 

meningitis, 166 

osteitis of scapula, 446 

osteomyelitis of ribs, 455 
of sternum, 455 

osteoperiostitis of tibia, 588 

stricture of rectum, 554 

ulcers of leg, 583 
of rectum, 553 

urethritis, 669 
Syringomyelia, 196 
Syringomyelic arthropathy, 138 



Tabes dorsalis, 197 

Tabetic arthropathy, 138, 579, 632 

Tarsal joints, arthritis of, 576 

scaphoid, fracture of, 565 
Tarsus, dislocations of, x-rays in diagnc 

of, 49 
Teeth, caries of, 289 

cementum of, hyperplasia of, 291 

impacted, 291 

roots of, abscess of, 290 
inflammation of, 290 
Telangiectasis, 99 
Temporal lobe, tumors of, 177 
Temporomaxillary articulation, 286 
arthritis of, 287 
luxation of, 287 
sprains of, 287 
Tendons, fibroma of, 115 

fibrosarcoma of, 115 

of foot, dislocations of, 572 
rupture of, 574 

of forearm, rupture of, 371 

inflammation of, 112 

lipoma of, 115 

luxation of, 112 

rupture of, 112 

syphilis of, 112 

trauma of, 112 

tumors of, 115 

wounds of, 112 
Tenosynovitis, 112, 574 

acute, 371 

gonorrheal, 365 

gummatous, 115 

syphilitic, 114 

tuberculous, 364 
Tenth nerve, functions of, 153 
Teratoma of neck, 307 

of orbit, 266 
Testicle, congenital anomalies of, 651 

contusion of, 653 

cysts of, 656 

dislocation of, 653 

inversion of, 652 

neuralgia of, 658 

retention of, 651 



INDEX 



767 



Testicle, syphilis of, 658 

torsion of, 652 

tumors of, 658 

undescended, 638 
Tetanus, 76 

Tetany, postoperative, 327 
Thigh, carcinoma of, 618 

contusions of, 615 

cysts of, 619 

inflammations of, 617 

lipoma of, 618 

muscles of, hernia of, 615 
rupture of, 615 

sarcoma of, 618 

tumors of, 618 
Third nerve, functions of, 151 
Thoracic duct, inflammation of, 101 
rupture of, 101 
wounds of, 101 

nerves, diseases of, 222 
paralysis of, 221 
Thorax, abscess of, 452 

carcinoma of, 460 

cellulitis of, 451 

concussion of, 453 

congenital malformations of, 451 

contusion of, 453 

epithelioma of, 461 

fibroma of, 460 

gunshot injuries of, rr-rays in diag- 
nosis of, 59 

inflammations of, 455 

lipoma of, 460 

sarcoma of, 460 

traumatism of, 453 

tumors of, 460 

wounds of, 453 
Thrombosis, 96 

of kidney, fever of, 73 
Thrombotic external hemorrhoids, 546 
Thrush, 288 
Thymus death, 331 

gland, diseases of, 331 
Thyroid gland, carcinoma of, 330 
congestion of, 327 
echinococcus cysts of, 331 
inflammation of, 327 
sarcoma of, 329 
scirrhus of, 331 
tumors of, 328 
Thyroiditis, acute, 327 
Tibia, abscess of, 591 

dislocation of, 606 

exostoses of, 613 

fracture of, 584, 604 

inflammation of, 587 

osteomyelitis of, 588 

osteoperiostitis of, 587, 588 

sarcoma of, 595, 614 

tubercles of, separation of, 605 

tuberculosis of, 592 
Tibiotarsal dislocation, 572 
Tic douloureux, 215 

facial, 216 
Tinea of axilla, 438 

circinata, 87 



Tinea cruris, 88 

favosa, 86 

tonsurans, 87 

versicolor, 89 
Toe, hammer, 556 

nail, ingro^\'ing, 563 
Tongue, actinomycosis of, 294 

angioma of, 294 

cancer of, 294 

chancre of, 293 

cysts of, 295, 296 

fibroma of, 295 

inflammation of, 292 

lipoma of, 295 

malformations of, 292 

mucous patches of, 293 

sarcoma of, 295 

syphilis of, 293 

tuberculosis of, 293 

tumors of, 294 

ulcers of, 292 
Tongue-tie, 292 
Tonsillitis, acute, 296 

diphtheritic, 297 

follicular, fever of, 73 

ulceromembranous, 297 
Tonsils, abscess of, 296 

carcinoma of, 298 

gumma of, 297 

chancre of, 297 

hypertrophy of, 296 

inflammation of, 296 

sarcoma of, 297 

syphilis of, 297 

tuberculosis of, 297 

tumors of, 297 
Torsion of omentum, 493 

of testicle, 652 
Torticolhs, 218 

acquired, 309 

congenital, 307 
Toxic myositis, 108 
Trachea, foreign bodies in, 323 

rc-rays in diagnosis of, 59 

stenosis of, 324 
Trachoma, 263 

Transudates, examination of, 34 
Trauma of ankle, 564 

of arm, 418 

of bladder, 673 

of bloodvessels, 96 

of bones, 118 

complications and sequels of, 78 

of elbow, 390 

of foot, 564 

of forearm, 371 

of hip, 623 

of joints, 131 

of knee, 598 

of liver, 518 

of muscles, 107 

of neck, 308 

of nose, 272 

of penis, 640 

of rectum, 552 

of shoulder, 418 



768 



INDEX 



Trauma of spine, 336 

of spleen, 530 

of stomach, 510 

of tendons, 112 

of thorax, 453 
Traumatic aneurysms, or-rays in diag- 
nosis of, 66 

arthritis, 133, 136 
of elbow, 414 
of hand, 366 
of hip, 628 

of knee-joint, 609, 610 
of wrist, 366 

aseptic fever, 69 

dislocation of hip, a:-rays in diag- 
nosis of, 47 

encephalohydrocele, 230 

gangrene, 99, 365 

hysteria, 212 

hystero-neurasthenia, 214 

myositis, 108 

neurasthenia, 211 

neuroses, 211 

osteomyelitis, 122 

osteoperiostitis, acute, 120 
of tibia, 587 

rupture of urethra, 666 

spondylitis, chronic, 342 

ulcer of hand, 362 

urethritis, 668 
Triceps clonus, 156 

reflex, 156 
Trigeminus nerve, functions of, 152 
Trigger-finger, 348 
Trochanteric bursitis, 628 
Trochlear nerve, functions of, 152 
Trophic ulcers of hand, 365 
Tubal pregnancy, 730 
Tubercle bacilli in sputum, 32 
Tuberculous meningitis, 202, 225 

in infants, 203 
Tuberculosis of adrenal gland, 692 

of arms, 549 

of bladder, 678 

of bone, 123 

a;-rays in diagnosis of, 39 

of brain, 165 

of breast, 464, 468 

of bursa, 116 

of cecum, 498 

of epididymis, 657 

of esophagus, 474 

of eyelids, 259 

of face, 247 

of fibula, 592 

of forearm, 384 

of hand, 364 

of hip, 629 

of humerus, 445 

of intestines, 538 

of jaw, 284 

of joints, 135, 137 

of kidneys, 690 

of larynx, 324 

of liver, 519 

of lungs, 459 



Tuberculosis of lymph glands, 305 
of metacarpal bones, 367 
of muscles, 109 
of nose, 274 
of palate, 299 
of penis, 646 
of peritoneum, 480 
of phalanges, 367 
of sacro-iliac joint, 636 
of scalp, 233 
of seminal vesicles, 661 
of skin, 94 
of spine, 340 
of spleen, 531 
of tendons, 113 
of tibia, 592 
of tongue, 293 
of tonsils, 297 
of ureter, 682 
of uterus, 726 
of wrist, 367 
Tuberculous adenitis, 105 

of axillary glands, 442 

of groin, 639 
arthritis of elbow, 415 

of joints of ankle, 577 

of knee-joint, 611 

of shoulder, 447 

of temporomaxillary articula- 
tion, 287 

a:-rays in diagnosis of, 49 
fistula of anus, 548 
infection, 75 
lymphadenitis, 312 
lymphangitis, 102 
osteitis of scapula, 446 
osteomyelitis of ribs, 456 

of sternum, 456 
prepatellar bursitis, 607 
sinus, 247 

stricture of rectum, 554 
tenosynovitis, 364 
ulcers of leg, 583 

of rectum, 553 
urethritis, 670 
Tumors, 82 

of abdomen, 486 

x-rays in diagnosis of, 65 
of anus, 550 
of arm, 447, 519 
of auricle, 254 
of bladder, 494, 678 
of bloodvessels, 99 
of bone, 127 

a;-rays in diagnosis of, 43 
of brain, 163 

x-rays in diagnosis of, 55 
of breast, 464, 468 
of bursa, 117 
carotid, 306 
of Cauda equina, 206 
of cerebellum, 179 
of cervix, 717 
of coccyx, 334 
of conjunctiva, 263 
of crus, 178 



INDEX 



769 



Tumors of ear, 256 
of face, 250 
of forearm, 384 
of foot, 579 
of frontal lobe, 171 

sinus, 277 
of gall-bladder, 496 
of hand, 368 
of intestines, 357 
of jaw, 285 

rc-rays in diagnosis of, 55 
of joints, 139 
of kidney, 496, 691 

a;-rays in diagnosis, 63 
of knee-joint, 613 
of larynx, 325 
of leg, 595 
of lips, 280 
of liver, 493, 519 
of lung, 462 

of maxillary sinus, 276 
of mediastinum, 462 
of medulla oblongata, 178 
.of motor area of brain, 174 
of mouth, 289 
of muscles, 110 
of nasopharynx, 278 
of neck, 312 

congenital, 307 
of nerves, 222 
of nose, 275 
of occipital lobe, 176 
of orbit, 264 
of ovary, 732, 734 
of palate, 299 
of pancreas, 527 
of parotid glands, 301 
of penis, 646 
perirectal, 555 
phantom, 489 
of pleura, 462 
of pons, 178 
of prostate, 664 
of pylorus, 493 
of rectum, 554 
of ribs, 461 

a:;-rays in diagnosis of, 57 
sacrococcygeal, congenital, 633 
of sacro-iliac joint, 637 
of sacrum, 334 
of salivary glands, 304 
of scalp, 238 
of scrotum, 651 
of sensory area of brain, 175 
of shoulder, 447 
of skull, 238 

a:-rays in diagnosis of, 55 
of spinal cord, 205 
of spine, 343 
of spleen, 531 
of sternum, 461 

x-rays in diagnosis of, 57 
of stomach, 493, 514 
of subcortical area of brain, 178 
of submaxillary gland, 306 
suprarenal, 496, 497 
49 



Tumors of suprarenal gland, 692 

of temporal lobe, 177 

of tendons, 115 

of testicle, 658 

of thigh, 617 

of thorax, 460 

of thyroid gland, 328 

of tongue, 294 

of tonsils, 297 

of umbilicus, 489 

of uterus, 722 

of vagina, 714 

of vertebra?, 206, 343 

a:-rays in diagnosis of, 57 

of visual area of brain, 176 

of vulva, 709 

of wrist, 368 
Twelfth nerve, functions of, 153 
Tympanites, 490 
Tympanum, cancer of, 257 

congestion of, 255 

pol3^pi of, 257 

wounds of, 254 
Typhoidal arthritis, 135, 628 

osteomyelitis of ribs, 455 
of sternum, 455 

osteoperiostitis, 121, 588 

spondylitis, 342 



Ulcer of cornea, 266 

of duodenum, 515 

of esophagus, 474 

of foot, 563 

of hand, 362, 365 

of intestines, 535 

of leg, 582, 583 

of lips, 279 

of nose, 273 

of penis, 646 

of rectum, 552, 553 

of stomach, 513 

of tongue, 292 
Ulna, dislocations of, 412 

fractures of, 380 

coronoid process of, 405 
Ulnar nerve, paralysis of, 221 

styloid, dislocation of, 358 
fracture of, 357 
Umbilical hernia, 505 
Umbilicus, abscess of, 490 

carcinoma of, 489 

congenital anomalies of, 489 

eczema of, 490 

gumma of, 489 

lipoma of, 489 

myxoma of, 489 

sarcoma of, 489 

tumors of, 489 
Undescended testicle, 638 
Urachus, cyst of, 489 
Ureters, anomalies of, 679 

calculi of, 680 

carcinoma of, 682 



770 



INDEX 



Ureters, fistula of, 681 

inflammation of, 680 

rupture of, 679 

stricture of, 680 

tuberculosis of, 682 

wound of, 680 
Urethra, abscess of, 668 

atresia of, 707 

foreign bodies in, 667 

inflammation of, 667 

malformations of, 666 

polyps of, 670 

rupture of, traumatic, 666 
Urethral caruncle, 735 

epididymitis, 654 
Urethritis, 667, 735 

acute traumatic, 668 

chancroidal, 669 

chronic, 669 

diphtheritic, 669 

eruptive, 668 

gonococcic, 668 

infectious, 668 

pneumococcic, 669 

syphilitic, 669 

tuberculous, 670 
Urine, acetone in, 26 

albumin in, 24 

bacteriology of, 27 

Bence-Jones body in, 25 

bile pigment in, 27 

blood in, 26 

/?-oxybutyric acid in, 26 

diacetic acid in, 26 

examination of, 23 
cryoscopy in, 24 

fibrin in, 25 

glucose in, 26 

melanin in, 27 

nucleo-albumin in, 25 

parasites of, 27 

peptones in, 25 
Urticaria, 90 

of foot, 562 

of penis, 641 
Uterus, bicornate, 720 

carcinoma of, 722 

chorio-epithelioma of, 726 

descending, 720 

displacements of, 720 

double, 720 

fibroids of, 724 

hematometra of, 726 

infantile, 720 

inflammations of, 721 

inversion of, 726 

malformations of, 720 

newgrowths of, 722 

physometra of, 726 

prolapse of, 720 

pyometra of, 726 

retroposition of, 720 

sarcoma of, 723 

septate, 720 

tuberculosis of, 726 
Uveitis, 267 



Vagina, absence of, 713 

atresia of, 713 

carcinoma of, 714 

cysts of, 714 

fibromyoma of, 714 

inflammation of, 713 

malformations of, 713 

sarcoma of, 714 

tumors of, 714 
Vaginitis, 713 
Varices of esophagus, 474 
Varicocele, 659 
Varicose veins of leg, 580 

of vulva, 709 
Vascular goitre of neck, 315 

keratitis, 267 

wounds of neck, 309 
Venereal warts of cervix, 717 

of vulva, 709 
Venous hemorrhoids, 551 
Ventral hernia, 506 
Verruca of scalp, 238 
Vertebrae, caries of, a;-rays in diagnosis of, 
57 

fractures of, a:-rays in diagnosis of, 57 

injury of, 207 

sprain of, 207 

syphiUs of, 343 

tuberculosis of, 340 

tumors of, 206, 343 

a;-rays in diagnosis of, 57 

wounds of, 340 
Vesical calculus, 675, 736 

x-rays in diagnosis of, 63 

fistula, 735 

sphincter, internal, contracture of, 
664 _ 
sclerosis of, 664 
Vesiculitis, acute, 660, 661 
Visual centres of brain, 144 

timiors of, 176 
Vitelline duct, persistent, 489 
Volkmann's contracture of hand, 348 
Volvulus of stomach, 513 
Vomiting, postoperative, 78 
Vulva, carcinoma of, 710 

chancre of, 709 

chancroid of, 709 

elephantiasis of, 708 

enlargements of, 709 

fibromyoma of, 712 

hematoma of, 710 

herpes of, 709 

infantile, 707 

inflammation of, 707 

lipoma of, 712 

lupus of, 712 

malformations of, 707 

sarcoma of, 712 

syphilis of, 709 

tumors of, 709 

varicose veins of, 709 

venereal warts of, 709 
Vulvitis, 707 



INDEX 



771 



Vulvovaginal glands, abscess of, 712 
cysts of, 713 
inflammation of, 712 



W 



Warts, 94 

of scalp, 238 / 

venereal, of cervix, 717 
of vulva, 709 
Wasserman reaction in diagnosis of 

syphilis, 35 
Wens, 240 
Widal reaction, 22 
Word blindness, 144 
Wounds of arm, 418 , 

of bladder, 673 

of bloodvessels, 96 

of buttocks, 633 

of chest, 453 

of ear, 254 

of elbow, 390 

of forearm, 379 

of heart, 453 

of joints, 131 

of knee, 598 

of lungs, 453 

of neck, vascular, 309 

of penis, 640 

of skull, 231,232 

of spine, 340 

of spleen, 530 

of stomach, 511 

of tendons, 112 

of thoracic duct, 101 

of tympanum, 254 

of ureters, 680 

of vertebrae, 340 
Wrist, arthritis of, 366, 367 

bones of, dislocations of, 358 
fractures of, 352 
inflammations of, 366 

dislocations of, 357 

drop, 347 

inflammation of, 358 

joints of, inflammations of, 366 
peri-arthritis of, 366 

sprains of, 349, 352 

subluxation of, 358 

tumors of, 368 
Writer's cramp, 348 
Wry-neck, 218 

acquired, 309 

congenital, 307 



Xanthoma of eyelids, 260 
Xerosis of conjunctiva, 263 
X-rays in diagnosis of abdominal aneu- 
rysms, 64 
tumors, 65 
of abscess of lung, 61 
of achondroplasia, 42 



X-rays in diagnosis of acromegaly, 42 
of aneurysms, 59 
of arteriosclerosis, 66 
of arthritis, 49 

acute, 49 

chronic, 49 

non-tuberculous, 50 
tuberculous, 49 

gouty, 53 

infectious, 52 

of spinal column, 58 
of arthropathies, 53 
of biliary calculus, 64 
of bone cysts, 44 
of bunion, 54 
of bursitis, 66 
of carcinoma of bone, 45 
of caries of vertebrae, 57 
of cervical rib, 54 
of coxa vara, 54 
of deformities of ribs, 57 
of diseases of bones, 37 

of colon, 66 

of esophagus, 65 

of gall-bladder, 64 

of joints, 37 

of liver, 64 

of lumbar spine, 65 

of nose, 54 

of pancreas, 64 

of sigmoid, 66 

of small intestine, 66 

of spleen, 64 

of sternum, 57 

of stomach, 65 

of teeth, 55 
of dislocations, 46 

acromioclavicular, 47 

of carpal bones, 47 

of elbow- joint, 47 

of hip, congenital, 47, 54 
traumatic, 47 

of shoulder- joint, 47 

of sternum, 57 

of tarsus, 49 
of empyema, 62 
of enchondroma of bone, 45 
of epiphyseal separations, 39 
of epiphysitis, 39 
of foreign bodies in abdomen, 64 
in bladder, 64 
in bronchi, 59 
in esophagus, 58 
in eye, 54 
in head, 54 
in larynx, 59 
in orbit, 54 
in pelvis, 64 
in trachea, 59 
of fractures of, 37 

of ribs, 56 

of sternum, 57 

of vertebrae, 57 
of fragilitas ossium, 42 
of gangrene of lung, 61 
of genu valgum, 54 



772 



INDEX 



X-rays in diagnosis of genu varum, 54 

jf gunshot injuries of thorax, 5f 
of hereditary syphilis of bone, 

42 
of hydronephrosis, 63 
of inflammations of bones, 39 
of loose bodies in joints, 53 
of myositis, 66 
of nephroptosis, 63 
of osteitis deformans, 42 
of osteoma, 45 
of osteomyelitis, 39 
of osteoperiostitis, 56 
of osteosarcoma, 44 
of painful stump, 67 
of perinephric abscess, 63 
of periosteitis, 39 
of pleural effusions, 62 
of pneumonia, 61 
cf post-typhoidal osteitis, 42 
of prostatic calculi, 63 



X rays in diagnosis of pyonephrosis, 63 
of renal calculus, 62 
of rickets, 43 
of rupture of muscles, 67 
of salivary calculus, 55 
of sarcoma of bone, 41, 43 
of scoliosis, 54, 58 
of subphrenic abscess, 62 
of syphilis of bones, 40 
of syphilitic dactylitis, 42 
of traumatic aneurysms, 66 
of tuberculosis of bones, 39 
of tumors of bone, 43 

of brain, 55 

of kidney, 63 

of lower jaw, 55 

of ribs, 57 

of skull, 55 

of sternum, 57 

of vertebrae, 57 
of vesical calculus, 63 



